Tuesday 15 October
08:30

Tuesday 15 October

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A30
08:30 - 09:00

KEYNOTE LECTURE 2

Moderator: Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
08:30 - 09:00 What It Takes To Be a Leader: Leadership Concepts In The ED. Greg HENRY (USA)
CONGRESS HALL
09:10

Tuesday 15 October

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A31
09:10 - 10:40

Disaster medicine
Climate change impacts on health
Disaster medicine

Moderators: Pr Francesco DELLA CORTE (Speaker) (Novara, Italy), Pr Ives HUBLOUE (Chair) (Brussels, Belgium)
09:10 - 10:40 Heat Waves. Dr Joris VAN LOENHOUT (Senior Research Fellow) (Brussels, Belgium)
09:10 - 10:40 Air Pollution. Paul WILKINSON (Environmental epidemiology) (London, United Kingdom)
09:10 - 10:40 Floods. Johan VON SCHREEB (Professor) (Stockholm, Sweden)
CONGRESS HALL

Tuesday 15 October

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B31
09:10 - 10:40

Ethics and Philosophy
Do We Always Have to Save the Life?
Ethics, INTERACTIVE SESSION, Palliative Care, Philosophy

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, Greece), Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany)

09:10 - 09:30 Possibilities & Perspectives for Palliative Care in the ED: The Next Frontier in EM? Robert LEACH (Head of Dept.) (BRUXELLES, Belgium)
09:30 - 09:50 Repeated Suicide Attempt - is there an obligation to live? Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester)
09:50 - 10:10 Treatment Strategies and Case Scenarios with TED Questions. Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany)
10:10 - 10:20 End-of-Life Care in the ED: Ethical Issues. Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, Greece)
10:20 - 10:40 Panel Discussion. Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester), Robert LEACH (Head of Dept.) (BRUXELLES, Belgium), Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, Greece)
FORUM HALL

Tuesday 15 October

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C31
09:10 - 10:40

Education in emergency medicine
Tips, tricks and politics in EM education
Education

Moderators: Cristian BOERIU (Assoc.Professor) (Targu Mures, Romania), Eric DRYVER (Consultant) (Lund, Sweden)
09:10 - 09:25 Assessment. Greg HENRY (USA)
09:25 - 09:40 How to prove that what your teach makes a difference? Dr Damian ROLAND (Paediatric EM) (@damian_roland, United Kingdom)
09:40 - 09:55 Implementing New Processes in Your ED: Tips from the Trenches. Eric DRYVER (Consultant) (Lund, Sweden)
09:55 - 10:10 Catch as Catch Can. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
10:10 - 10:40 Panel discussion. Eric DRYVER (Consultant) (Lund, Sweden), Greg HENRY (USA), Dr Damian ROLAND (Paediatric EM) (@damian_roland, United Kingdom), Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
SOUTH HALL 3AB

Tuesday 15 October

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D31
09:10 - 10:40

YEMD - Learn to lead!
Hear about personal experiences, learn why we need more women in EM and be part of the discussion!
Leadership, Women in EM, Young Emergency Medecine

Moderators: Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, Lithuania), Basak YILMAZ (Faculty) (BURDUR, Turkey)
09:10 - 10:40 Changing society and medicine. Martynas GEDMINAS (Physician / Quality control) (Šiauliai, Lithuania)
09:10 - 10:40 From hero to zero and back. Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, Belgium)
09:10 - 10:40 Female rollercoaster in Emergency Medicine. Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, Lithuania)
SOUTH HALL 3C

Tuesday 15 October

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E31
09:10 - 10:40

NURSES
Organization of emergency nursing care
Neurology, Nurses, Triage

Moderators: Dr Kris BRAEKERS (Assistant Professor) (Hasselt, Belgium), Dr Remco EBBEN (Associate professor/lecturer) (Nijmegen, The Netherlands)
09:10 - 10:40 Integrated triage. Tessa POSTUMA (Trainer) (DOETINCHEM, The Netherlands)
09:10 - 10:40 The organization of acute neurovascular care. Peter STAP (Nurse Practitioner) (The Hague, The Netherlands), Rianne LAM (NP) (Den Haag, The Netherlands)
09:10 - 10:40 What last years literature learned us about: ED crowding. Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, The Netherlands)
CHAMBER HALL

Tuesday 15 October

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F31
09:10 - 10:40

ABSTRACTS SESSION

Moderators: Dr Rodrick BABAKHANLOU (M.D. M.Sc.) (Edinburgh), Felix LORANG (Consultant) (Jena, Germany)
09:10 - 09:20 #18693 - OP064 Use of non invasive ventilation: experience of a tunisian emergency department.
OP064 Use of non invasive ventilation: experience of a tunisian emergency department.

Introduction:

Non Invasive Ventilation (NIV) use in acute respiratory failure (ARF) is mostly initiated in Emergency

Department (ED) before patient transfer to Intensive Care Unit (ICU) or Respiratory Ward (RW). In Tunisia, because of the limited ICU beds’ number and the absence of NIV in RW, patient requiring NIV are admitted in ED.

Aim: To describe our experience with non-invasive ventilation in emergency department (ED).

Methods:

A prospective observational monocentric study conducted for a six months period in the Emergency Department of the University Hospital FarhatHached, Sousse-Tunisia. We included patients consulting for non traumaticARF requiring NIV.

We analyzed the NIV characteristics in the first 24 hours and evaluated patients ‘outcomes. NIV success was defined as no need for endotracheal intubation (ETI).

Results:

During the study’s period, we included 63 patients. During the first 24 hours of the studied population’s ED

stay, 142 sessions were delivered with a mean duration of 9,47 ±3,38h. The median value of NIV initiating delay (defined by the time from the patients’ registration until NIV initiation) was one hour [0-3h]. The first-line ventilating mode used was BiPAP in 55 patients (87.3%) with a mean IPAP 11,8±1,2 cmH2O , a mean EPAP of 4,49±1,07 cmH2O and a mean FiO2= 39,38±11,26%.

NIV failed in 8 patients (12.7%) with a median value of intubation delay about 4 h [0-14].

After a median ED length of stay of 40 h [24-53 h] and total NIV duration of 15 h [8-31 h], 26 patients (41,3%) were transferred to ICU, 21 to medical ward and 13 patients (20,6%) were discharged at home. The global mortality in our studied population was 4.8% (3 patients).

Conclusion:

Our results confirm the global efficacy of NIV in an ED setting. Therefore, young emergency physicians should be provided with protocols and guidelines for NIV practice.


Mariem KHALDI, Mariem KHROUF, Dr Ahmed MAHMOUDI (Sousse, Tunisia), Hajer SANDID, Hayfa SNOUSSI, Zied MEZGAR, Mehdi METHAMEM
09:20 - 09:30 #18022 - OP065 Variability in utilization and diagnostic yield of Computed Tomography Pulmonary Angiography (CTPA) scans for pulmonary embolism among emergency department (ED) physicians: a retrospective observational study.
OP065 Variability in utilization and diagnostic yield of Computed Tomography Pulmonary Angiography (CTPA) scans for pulmonary embolism among emergency department (ED) physicians: a retrospective observational study.

Background:

Current data on utilization of CT imaging point to a trend of increasing overutilization of CT Angiography for the diagnosis of pulmonary embolism (CTPA) over time. Multiple educational and institution-wide interventions addressing this overutilization have been proposed, implemented and evaluated, with mixed results in terms of long-term impact on physician ordering behaviour. The objective of this study is to examine the inter-physician variability in ordering rates and diagnostic yield of CTPA, under a working hypothesis that a small number of physicians are responsible for a disproportionately high number of CTPA ordered in the ED, and that disproportionately high ordering rates are associated with lower diagnostic yield.

Methodology:

Data was collected on all CTPA studies ordered by ED physicians at two very high volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. Analysis was limited to those ED physicians who had a total of greater than 500 ED visits over the course of the 2-year period. For each physician, two calculations were made: 1) CT PE ordering rate (total number of CTPA ordered divided by the total number of ED visits), and 2) CTPA diagnostic yield (total number of CTPA positive for PE divided by the total number CTPA ordered). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Results:

A total of 2,789 CTPA were ordered by 84 physicians for 461,045 total ED visits. Preliminary results show a great deal of variation in ordering rates, ranging from 0.9 to 22.2 CTPA per 1000 ED visits (median = 4.8 CTPA per 1000 ED visits, IQR = 4.5 CTPA per 1000 ED visits). Similarly, there was a high degree of variation in CT PE yield, ranging from 0% to 50% (median = 9.6%, IQR = 13.1%). Those physicians in the top quartile for ordering rate had a lower mean diagnostic yield, when compared to the lower quartiles (8.9% when compared to 11.5%, 11.9% and 18.2% for the physicians in the third, second, and first quartile respectively).

Conclusion:

The findings of this study indicate a wide degree of variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields. However, the more interesting lessons from this initial study center on the challenges in creating an audit-and-feedback program targeting CTPA ‘overutilizers’.


Leila SALEHI, Prashant PHALPHER, Christopher MEANEY, Marc OSSIP, Dr Rahim VALANI (Toronto, Canada)
09:30 - 09:40 #18520 - OP066 Adding lung ultrasound to standard diagnosis procedure for the diagnosis of community-acquired pneumonia in the emergency department: prospective multicenter observational study (echopac)).
OP066 Adding lung ultrasound to standard diagnosis procedure for the diagnosis of community-acquired pneumonia in the emergency department: prospective multicenter observational study (echopac)).

Background

The diagnosis of community-acquired pneumonia (CAP) in the Emergency Department (ED) is often difficult due to limitations of clinical examination, chest X-ray and laboratory tests. A recent study showed that computerized tomography (CT) scan modified the clinical probability of CAP in 58% of the cases. However, CT scan is not applicable for all patients with suspected CAP in the ED. Thus, our goal was to investigate another tool, early Lung Ultrasound (LUS), to improve CAP diagnosis, by accessing changes in diagnostic probability and antibiotic initiation induced by LUS.

Methods

It was a prospective observational study in 4 French ED between 8/11/2016 and 31/12/2018. Included patients were a convenience sample of patients older than 18 years with a suspicion of CAP before medical exam. Exclusion criteria were documented palliative care or the need of immediate intensive care.

After informed consent approval and usual diagnosis procedure (UDP) (clinical, radiological and biology), the Emergency Physician established a CAP probability using a Likert scale (definite, probable, possible, excluded) and intention for antibiotics treatment initiation. A LUS was then performed, another probability (LUSP) for CAP diagnosis and treatment initiation was established. An adjudication committee established the final probability of CAP (COMP) at D28.

The main objective was the concordance rate between LUS and UDP probability according to COMP probability. Secondary objectives were probability changes induced by LUS and antibiotics changes. Categorical data expressed as percentage [95% confidence interval] were compared with Mac Nemar test.

The study was approved by the ethical committee and registered on clinicaltrial.gov (NCT03411824). There was no funding. For a probability concordance of 55% before LUS and 80% after with alpha 0.05 and beta 0.10, the required number of patients was 144.

Results

150 patients were recruited, two secondarily excluded because of wrong identification, leaving 148 analyzed patients: 70 women and 78 men, mean age 72 + 18 years old. UDP probability was definite in 34 patients (23%), probable in 52 (35%), possible in 56 (38%) and excluded in 6 (4%). LUS induced a probability modification in 109 patients (73 % [66-80%]). LUS probability was definite in 93 patients (63%), probable in 15 (10%), possible in 9 (6%) and excluded in 31 (21%). 82 of these modifications (77 % [68-84%]) were in accordance with the adjudication committee. COMP probability was definite in 81 patients (55%), probable in 16 (11%), possible in 12 (8%) and excluded in 39 (26%). When compared to COMP probability, 39 out of 148 UDP probabiliies were correct (27% [20-35]) while 109 LUSP were correct (77% [71-84]), p<10-4. There were 45 modifications in antibiotic prescription (30% [24-38%]): 21 were prescribed after LUS while 24 were discontinued.

Discussion and conclusion

In this population comparable to other studies in literature, LUS was a powerful tool to improve the diagnosis accuracy. In particular, it decreased the diagnostic uncertainty (possible and probable probability from 73 to 16% after LUS).



clinicaltrial.gov (NCT03411824) no funding
François JAVAUDIN, Nicolas MARJANOVIC, Hugo DE CARVALHO, Benjamin GABORIT, Estelle BOUCHER, Denis HAROCHE, Philippe LE CONTE (Nantes)
09:40 - 09:50 #19023 - OP067 Variability of cardiac activity evaluation between physician sonographers: a validation study.
OP067 Variability of cardiac activity evaluation between physician sonographers: a validation study.

Background:

The absence of cardiac activity (CA) on point-of-care ultrasound (POCUS) during the cardiopulmonary resuscitation (CPR) is a known predictive factor for worse patient outcomes. However, the assessment of CA is challenging due to the urgency of the situation and lack of clear definition of CA. Although a previous study has shown the considerable variability in interpretation of CA among physician sonographers, it is not validated in different populations. The aim of our study is to examine the inter-person agreement of CA evaluation among physician sonographers.

Methods:

This was a cross-sectional questionnaire survey conducted between August 2018 and April 2019. The participants were recruited from 7 hospitals in Japan. All participants evaluated the 20 second echocardiographic video and answered the presence or absence of CA. This video consisted of 15 cases that were either CA positive (strong myocardial contraction, weak myocardial contraction, ventricular fibrillation) or CA negative (no cardiac motion, cardiac motion by bag valve mask ventilation, and valve flatter without myocardial contraction). Other questionnaire contents were as follows: specialty of the physician sonographer, self-reported general POCUS skill level, experience of echocardiography in CPR and post-graduated year (PGY). Our primary outcome was the overall inter-person agreement of CA evaluation. The inter-person agreement of CA evaluation was investigated using Krippendorff's alpha coefficient. Additionally, we conducted sensitivity analysis with different subgroups (specialty, self-reported general POCUS skill level, experience of echocardiography in CPR, PGY).

Results:

A total of 41 physician sonographers were recruited [23 emergency physicians (56.6%), 6 intensivists (12.2%), and 7 residents (17.1%)]. Self-reported general POCUS skill levels were basic (68.3%), advanced (29.3%), and expert (2.4%). The number of experiences of echocardiography in CPR was 0 (17.1%), 1-5 (17.1%), 6-10 (19.5%), 11-25 (14.6%), and >25 (31.7%). PGY was 1-2 (17.1%), 3-6 (36%), 7-10 (29.3%), and >11 (14.6%). The overall agreement rate of CA evaluation was moderate (α=0.53). Sensitivity analysis showed similar results [Self-reported general POCUS skill levels: basic (0.53), advanced (0.48), and expert (NA). The   number   of   experiences   of echocardiography in CPR: 0 (0.58), 1-5 (0.64), 6-10 (0.5), 11-25 (0.48), and >25 (0.5). PGY: 1-2 (0.66), 3-6 (0.56), 7-10 (0.49), and >11 (0.44)].

Discussion & Conclusions:

Similar to the previous study, there was a considerable variability in interpretation of CA among physician sonographers. Hence, it may be difficult to use this finding as a guide to terminating CPR. A clear definition of CA is warranted to precisely detect cardiac arrest patients with poor outcomes.



Trial Registration: This study wasn't registered because no patients involved. Funding: This study did not receive any specific funding. Ethical approval and informed consent: Not needed.
Hirokazu MAEDA (Obama Fukui, Japan), Hiroshi OKAMOTO
09:50 - 10:00 #19252 - OP068 Identifying low risk trauma patients to avoid whole-body CT prescription in the emergency department:an observational study.
OP068 Identifying low risk trauma patients to avoid whole-body CT prescription in the emergency department:an observational study.

Background: The Whole-Body computed tomography (WBCT) is a mainstay that guides the management of severely traumatized patients. However, its systematic use in the emergency department results in a high proportion of normal examinations. Its direct cost is significant and the irradiation of 20mSV exposes an adult to a risk of 1 in 1000 to develop cancer. The purpose of this study is to determine predictive criteria for normal examinations in trauma patients who have had an WBCT to rationalize its use. Methods: A monocentric retrospective study included trauma patients over 16 years of age for whom a WBCT was performed during their visit to the emergency department from 2016 to 2018. The endpoint for asserting the abnormality of the WBCT was at least one injury categorized 2 by the Abreviated Injury Scale. Anamnestic, clinical, radiological findings and patient management data were collected. Two approaches were used. The first was to define criteria based on scientific data to define a low-risk patient profile and to test the discriminating ability of this set of criteria. The second approach consisted in performing a multivariate analysis with a logistic regression model. On this occasion, the population was divided into two random samples corresponding to 50% of the initial population, one to create the model and the other to test it. The objective was to define a low-risk patient profile by testing the discriminating ability of this set of criteria to avoid the WBCT. Results: Out of 810 patients included 41% had an abnormal WBCT (n=329). Seventeen "a priori" criteria were tested simultaneously. The test performance showed a sensitivity of 96.9%, specificity of 25.8%, negative predictive value of 89.7%, positive predictive value of 48.2%. This method avoided one in seven WBCT. In the multivariate logistic regression model, 9 variables were selected. The performance of this model showed a sensitivity of 87%, specificity of 44%, negative predictive value of 81.3% and positive predictive value of 50%. The OCR curves showed an area under the curve of 0.8 for the learning sample and 0.73 for the test sample. This method avoided one in four WBCT in the learning group and one in five WBCT in the test group. Discussion: The "a priori" approach seems more robust in predicting the normality of the WBCT. False-negative patients in the multivariate model are more numerous and have more serious injuries missed. Rationalization of the WBCT in trauma patients is possible by a predictive algorithm. Conclusions: An external validation through a multicentric prospective study is required to validate this predictive model.



Mehdi TAALBA (ROUEN), Clotilde BOUVY, Andre GILLIBERT, Luc-Marie JOLY, Stefan DARMONI, Matthieu SCHUERS
10:00 - 10:10 #18718 - OP069 Usefulness of the initial diagnostic point-of-care ultrasonography urinary stone protocol for emergency department patients with acute renal colic: a randomized controlled study.
OP069 Usefulness of the initial diagnostic point-of-care ultrasonography urinary stone protocol for emergency department patients with acute renal colic: a randomized controlled study.

Background Detection of hydronephrosis by ultrasonography in patients with renal colic has good sensitivity and specificity for diagnosing ureter stones. This study investigated the effects of length of stay and total medical expense on patients with urolithiasis by applying the point-of-care ultrasonography urinary stone (POCUS-US) protocol in the emergency department (ED).

Methods We conducted a prospective randomized controlled trial for evaluating patients who visited the ED of the tertiary university hospital with acute renal colic between March and May 2019. The patients were separately enrolled according to day number of visitation in the ED. For those with odd day numbers (conventional group [CG]), we performed basic laboratory blood tests, urine analyses after history taking and physical examination, and additional tests, such as abdominal non-contrast computerized tomography (CT) based on the test results. For those with even day numbers (ultrasonography group [UG]), we performed bedside sonography simultaneously with physical examination and history taking to evaluate hydronephrosis. If hydronephrosis was detected, we proceeded to perform abdominal non-contrast CT promptly and laboratory tests, including only urine and creatinine blood level analyses. If patients in the UG did not have hydronephrosis, we examined them as we did the other patients in the CG. The patients were followed-up for acute renal failure and urinary tract infection and acutely missed or delayed high-risk diagnosis within 30 days. We investigated the ED length of stay and total medical costs as outcomes.

Results Ninety-one patients were enrolled, of which 72 were finally diagnosed as having ureter stones. The ED length of stay for the UG was 156 minutes (95% confidence interval [CI], 137–176 minutes) and was 78 minutes lesser than that for the CG (234 minutes; 95% CI, 210–259 minutes). The medical expense for the UG in the ED was approximately 30% lower than that for the CG (239 USD vs. 332 USD, respectively; P < 0.001). The incidence of complications within 30 days and acutely missed or delayed high-risk diagnosis were not significantly different between the two groups.

Conclusion Therefore, applying the initial diagnostic POCUS-US protocol for patients with acute renal colic in the ED can significantly reduce the ED length of stay and medical expense.


Seok Goo KIM (Seoul, Korea, Republic of), Ik Joon JO, Hee YOON
10:10 - 10:20 #18334 - OP070 Prevalence and Utility of Point-Of-Care Ultrasound in the Emergency Department: a prospective observational study.
OP070 Prevalence and Utility of Point-Of-Care Ultrasound in the Emergency Department: a prospective observational study.

Abstract

 

OBJECTIVE: An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments (ED).

 

BACKGROUND:Point of Care Ultrasound (POCUS) has been recognised as a useful noninvasive, bedside tool, providing additional information as well as it’s utility in procedural guidance for clinicians, However, its current use in the ED remains unknown.

 

METHODS: In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients’ presenting complaints, frequency, operators’ qualifications, and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified.

 

RESULTS:A total of 390 (2.82%) POCUS examinations were performed among 13,822 adult presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma (5.8%). Procedural POCUS was most commonly used for vascular access (57.9%), where dyspnoea (21.6%) was the most common presenting complaint. Majority of the cases were performed by FACEMs (fellows of Australasian college of Emergency Medicine) (67.7%). 

 

CONCLUSIONS: Despite known diagnostic and procedural advantages, the prevalence of POCUS in our EDs was found to be lower than what was expected. However, as this is a sigle network/centre study in a limited period of time,it might have resulted in under-reporting of POCUS use. In our study, POCUS mostly served for diagnostic purposes. Prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians should be further advocated and supported.

 


Dr Pourya POURYAHYA (Melbourne, Australia), Koo MEI-PING
10:20 - 10:30 #19301 - OP071 Influence of air pollution and climate variables on the number of hospital admissions due to exacerbation of COPD or asthma.
OP071 Influence of air pollution and climate variables on the number of hospital admissions due to exacerbation of COPD or asthma.

Background. A number of studies reported a link between air quality and negative health effects. Particularly, high levels of air pollutants are related to a worsening of chronic respiratory diseases, leading to an increased number of hospital admissions and outpatient visits. Several factors influence the exposure to intra-urban air pollution, such as traffic density and climate.

Aim. To assess the influence of air pollutant levels and climate data on the number of hospital admissions due to chronic obstructive pulmonary disease (COPD) and asthma exacerbations in Valladolid (Spain).

Material and methods. Retrospective ecological study. Time series of the number of COPD and asthma patients hospitalized in the Pneumology service between July 2014 and December 2017 due exacerbation of their condition were analyzed. Weekly average levels of sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), particulate matter with a diameter less than 2.5 (PM2.5) and 10 (PM10) micrometers, temperature (T), and rainfall (R) were obtained from publicly available data of the Valladolid city council. A generalized linear model with Poisson distribution was used to characterize the link between air pollution and climate variables with the number of admissions.

Results. A total of 1646 patients reported worsening of their COPD or asthma, which led to 2990 visits to the Emergency Department (ED) in the period of study: 1968 due to COPD and 1022 due to asthma exacerbation. 67.7% of patients visited ED one time, whereas 15.4% two times and 16.9% at least three times. Finally, 1644 individual admissions in the Pneumology service were assessed. Patients had a mean age of 66.0±5.9 years old (57.7% males). A significant correlation (p-value <0.05) between the number of hospitalizations and several independent variables (O3, PM2.5, NO2, CO, T, and R) was obtained. The CO concentration showed a significant high correlation (Rho 0.45; p <0.01) as well as the highest influence on the number of COPD/asthma-related admissions (odds ratio 3.06; CI95% 2.90-3.22). After considering confounding factors, the influence of carbon monoxide remains (odds ratio 1.33; CI95% 1.24-1.44). Similarly, the temperature also achieved a significant negative correlation (Rho -0.593; p <0.05) and showed a relevant link (odds ratio 0.96; CI95% 0.96-0.97) with the number of admissions.

Conclusion. Our results suggest that there is a significant association between the number of hospital admissions due to COPD and asthma exacerbations and ambient levels of carbon monoxide and temperature.


Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Ana CEREZO-HERNANDEZ, Daniel ALVAREZ, Fernando MORENO, Del Campo FELIX, Virginia CARBAJOSA RODRIGUEZ, Samsara LOPEZ, Irene CEBRIAN RUIZ, Henar BERGAZ DIEZ, Henandez Gajate MARIO, Jesus ALVAREZ MANZANARES, Jesus Angel MOCHE LOERI, Isabel GONZALEZ MANZANO, Jose Ramón OLIVAS RAMOS, Mª Antonia UDAONDO CASCANTE, Francisco MARTÍN RODRIGUEZ
10:30 - 10:40 #18714 - OP072 Side effects and complications of non-invasive ventilation in patients admitted to emergency department with acute respiratory failure.
OP072 Side effects and complications of non-invasive ventilation in patients admitted to emergency department with acute respiratory failure.

Background: The use of Non-Invasive Ventilation (NIV) for acute respiratory failure has increased during the past few decades in emergency department (ED) and has become widespread considering its various benefits (reducing the need for mechanical ventilation, improving survival rate). On the over hand, with the newfound beneficial treatments come complications and side effects.  are reported but few studies were published.

The aim of our study was to assess the side effects and complications when using NIV in patients admitted to ED with acute respiratory failure

Methods:    prospective observational study over a seven month period.  Inclusion of all consecutive patients admitted to ED with acute respiratory failure requiring NIV (CPAP or Bi-PAP mode). Considered indications were acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD), acute heart failure with pulmonary oedema or other indication). We didn’t include patients requiring NIV as a pre-oxygenation prior to intubation. A local protocol to perform NIV was followed. Demographics and clinical data were collected. Side effects and complications appearing during the NIV procedure were reported.

Results: Inclusion of 239 patients. Mean age 68±13. Sex ratio=1,6. Comorbidities n(%) : COPD 81(34), hypertension 139(58), diabetes 113(47), chronic heart disease 54(23), coronary heart disease 68(28,5). Indication of NIV n(%): AE COPD 59(25), acute pulmonary oedema 167(70).

CPAP was used in 172 patients (72%). CPAP complications and side effects (%): mouth dryness (34),tearing (18), face erythema (30), face pain and headache (26), skin erosion(9), nausea (7), vomiting (3), hypotension (2), rhinorrhea (2), abdominal pain(1). Success was obtained in 154 patients (89%). Bi-PAP NIV was required in 13 patients after CPAP failure. Invasive ventilation was performed in only four patients.

First line Bi-PAP ventilation was used in 67 (28). Bi-PAP complications and side effects (%): mouth dryness (28), face erythema (21), skin erosion (17), facial pain and headache (14), tearing (10), hypotension (4), rhinorrhea (4). Success was obtained in 83% of patients. Eleven patients was intubated.

Median hospital length stay was 28 hours [1-450]. Overall in-hospital mortality rate was 5,4%.

Conclusions: side effects were generally not severe but require the optimization of interfaces, use of humidifier or adequate positioning of patients. No infectious complications were reported. Severe side effects such as hypotension appear in less than 4% of patients. Trained both emergency physicians and paramedics is the key to reduce these complications.


Raja FADHEL, Ines CHERMITI, Emna ENNOURI, Hanène GHAZALI, Sana TABIB (Ben Arous-Tunisia, Tunisia), Rania ZAMMOURI, Monia NGACH, Mahbouba CHKIR, Sami SOUISSI
TERRACE 2B
10:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
10:45

Tuesday 15 October

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EPOSTER 4.1
10:45 - 11:05

ePoster 4.1 - Short Oral Presentation - Screen 1

Moderator: Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, Czech Republic)
10:45 - 10:50 #18971 - SP061 Treatment used in atrial fibrillation in patients with or without previous diagnosis of atrial fibrillation.
SP061 Treatment used in atrial fibrillation in patients with or without previous diagnosis of atrial fibrillation.

Introduction. Atrial fibrillation (AF) is the most frequently found sustained arrhythmia in the emergency department. The presence of AF complicates the management of patients presenting as medical emergencies. The treatment is focused on the control of the frequency and cardiac rhythm. AF is associated with an important morbimortality in the form of stroke, thromboembolism and heart failure.

Objective. The aim of the present study is to evaluate the drugs used in treatment of atrial fibrillation in patients with and without prior atrial fibrillation in the emergency department.

Methods. A descriptive observational, and retrospective study in a Hospital Comarcal Del Noroeste Murcia (a rural Centre of Spain) is described. In this study were included all patients aged 18 years with atrial fibrillation as diagnosis in emergency room from the 1st January to the 31th December 2017. We analyzed the pharmacological treatment.

Results. The sample under study is constituted by 209 patients: 116 with previous diagnosis of AF and 93 no. The patients with previous diagnosis of AF had average heart rate 103.27 bpm and the patients without previous AF had average heart rate 101.31 bpm. The treatment used in the emergency department in the patients with previous diagnosis of AF was: electrical cardioversion in 4.3% (5 patients), bisoprolol in 19.83% (23 patients), amiodarone in 20.69% (24 patients), digoxin in 16.38% (19 patients), flecainide in 8.62% (10 patients), diltiazem in 3.44% (4 patients), and other antiarrhythmics in 8.62% (10 patients). The treatment used in the emergency department in the patients without previous diagnosis of AF was: electrical cardioversion in 8.61% (8 patients), bisoprolol in 13.98% (13 patients), amiodarone in 11.84% (11 patients), digoxin in 16.13% (15 patients), flecainide in 4.3% (4 patients), diltiazem in 7.53% (7 patients), and other antiarrhythmics in 12.9% (12 patients). About the patients with previously AF, 54.68% had a sinus rhythm at discharge, and 45.32% remained in AF. Regarding patients without previous diagnosis of AF, 66% had a sinus rhythm at discharge, and 34% remained in AF. The mean time of staying at the emergency room was 508.14 minutes in patients with previously AF and 510.63 minutes in patients without previously AF.

Conclusion. We detected differences in the treatment between patients with de novo AF and previously diagnosis AF but the mean time staying in emergency room was similar in both groups. There is a greater tendency to perform electrical cardioversion in patients without previous AF. About the drugs, greater use was of Bisoprolol, Amiodarone and Digoxin in both groups. Bisoprolol is used in a lesser proportion in patients with previously AF, with greater use of Amiodarone. Sinus rhythm control was obtained in greater proportion in patients without previous diagnosis of AF. The mean time of staying at the emergency room was similar in both groups.


Nuria VICENTE GILABERT, Francisco Manuel RODRÍGUEZ RUBIO, Raquel CANTÓN CORTÉS, Carlos Máximo JAIME MORENO (Barcelona, Spain), Marta VICENTE GILABERT, Marta CAÑADILLA FERREIRA, Jorge ESCRIBANO POVEDA
10:50 - 10:55 #18171 - SP062 Putting out the fire: extinguishing burnout.
SP062 Putting out the fire: extinguishing burnout.

Background 

The 2018 national training survey carried out by the General Medical Council (GMC) in the UK demonstrated that one in four of 51,956 trainees and one in five of 19,193 trainers had feelings of burnout.  Burnout harbours increased risk of suicide, mental health issues, cardiovascular disease, relationship problems and substance abuse.  It can lead to detrimental patient care with a recent meta-analysis showing 2-fold increased odds for poorer patient safety and satisfaction along with increased unprofessional behaviour.  In this cross-sectional study, we sought to examine whether an innovative clinical fellow program in the emergency department (ED) at the Royal Sussex County Hospital (RSCH) has been beneficial to clinicians wellbeing.  Our aim is to demonstrate whether decreased levels of burnout are associated with the ED clinical fellow program. 

Methods 

The Copenhagen Burnout Inventory (CBI) was used and disseminated via email.  Scores of less than 25, 25 to 49, and 50 or more were categorized as low, intermediate, and high burnout.  All answers were anonymous.  The questionnaire was open between July and August 2018.  It was sent to doctors of four different specialities (orthopaedics, acute medicine, emergency medicine and general surgery) and of varying grades (FY1 level to consultant).  

 

Results  

There were 128 respondents with a response rate of 77% (n=165): emergency medicine (n= 51, 39.8%), acute medicine (n=36, 28.1%), orthopaedics (n=27, 21.1%), general surgery (n=14, 10.9%).  There were 25 consultants (19.5 %), 46 registrars (40 %) and 71 junior doctors (55.5 %).  The general surgery doctors had the highest total burnout scores (50.00+/-28.32) followed by emergency medicine (46.47+/-23.64), acute medicine (46.13+/-24.24), and orthopaedics (40.20+/-25.49). Junior doctors had the highest burnout scores (53.42+/-24.07), followed by consultants (44.48+/-24.12) and registrars (39.54 +/-21.86).  

ED clinical fellows had lower average burnout scores (38.95 +/- 24.84) than the rest of the respondents (45.43 +/-12.68), which was approaching significance (p=0.06).  When compared to all other respondents within ED (49.6 +/- 9.54), clinical fellows did have statistically significantly lower average burnout scores (p=0.002) 

 

Discussions and Conclusions  

Our surgical colleagues had the highest burnout scores.  There is ample data to suggest that it is emergency medicine clinicians that have amongst the highest levels of burnout and we presumed this would be the outcome. 

We can see a general trend of increasing burnout scores with decreasing seniority and this is consistent with other studies comparing different grades of clinicians.   

ED clinical fellows had lower burnout scores compared to all the other specialities and to the rest of the cohort within ED.  The ED clinical fellows have a different job plan and this could be the contributory factor to their improved well-being.  Their annualised rota, part time clinical work, simplified shift patterns and extracurricular projects along with a full workforce, 24 hour consultant cover and self-rostering for registrars appear to have combined into the perfect storm to positively affect clinician wellbeing.  More departments should be taking note of these change to try and mitigate against the devastating impact that burnout will have on the workforce and the individual it affects.  


Dr Catherine BERNARD (Brighton, United Kingdom), Sarah TYLER, Ben CAESAR, Ahmed BARAKAT, Donna BUTLER
10:55 - 11:00 #18244 - SP063 Outcomes of intra-arterial thrombectomy in acute ischemic stroke: direct transport versus transfer from another hospital.
SP063 Outcomes of intra-arterial thrombectomy in acute ischemic stroke: direct transport versus transfer from another hospital.

Background

There had recently been a surge in published studies documenting the effectiveness of mechanical intra-arterial thrombectomy (IA) as a treatment for patients with acute ischemia strokes(AIS).This study aim to identify whether there is benefit to direct transport patients with AIS to hospital that be able to provide IA

Methods

We retrospectively recruited all patients receiving IA as the treatment for AIS from January 2016 to December 2018. Neurologist was consulted for all AIS patients . IA criteria including 1. within 8 hours of the time last known to be well for anterior circulation stroke; within 24 hours of the time last known to be well for posterior circulation stroke,2. Computed tomography angiography demonstrated proximal large vessel occlusion,3. National Institutes of Health Stroke Scale (NIHSS) ≧8 or ≦30.Patients were divided into two groups: direct transport to our hospital or transfer from another hospital.The primary outcome of this study was the time since symptoms onset until the time of receiving IA. Our secondary outcomes were NIHSS 24 hours posttreatment , on discharge and Modified Rankin Scale (mRS) on discharge, 1 month follow up, 3 month follow up.

Results

In total, 254 patients were enrolled into this study after excluded those who met the aforementioned exclusion criteria. The majority was males (59.84%) and the transfer group had 148 (0.58) cases. There was no statistically significant in time between symptoms onset to IA between two groups. In the T- test analysis , there was statistically significant difference in NIHSS 24 posttreatment between these two groups(p=0.002).However, there were no significant difference in NIHSS on discharge in t- test analysis ,or mRS on discharge or further follow-up in chi-square test analysis .

Conclusions

In this retrospective study comprising 254 AIS patients receiving IA, we found there is no difference in NIHSS or mRS between those transferred from another hospital and those who visited our hospital directly.


Yenju CHEN (Taichung, Taiwan, China), Daming CHEN, Chihyu CHEN, Tai-Yi HSU, Weikung CHEN
11:00 - 11:05 #19347 - SP064 Levetiracetam :Worth a use in Status Epilepticus.
SP064 Levetiracetam :Worth a use in Status Epilepticus.

Case Vignette:

During one of the busy shifts in ED in a DGH, I received a pre alert regarding a 56 years old female who was having continuous seizures for past 30 minutes (SE) and had already received 10mg of P/R diazepam by the paramedics. On arrival she was still having generalized convulsive seizures and I quickly administered I /V LOR 4mg. She continued to seize despite of that and the decision was to give I/V PHT as per the guidelines. Her vital signs showed a SBP of 80mmhg and she had a background of AF.Despite knowing the fact that the most common side effects of PHT are hypotension and arrhythmias, we went ahead and gave the PHT to control the seizures, as per the guidelines. Patient became more hypotensive after that and needed inotropic support. The seizure activity stopped but patient needed RSI and was admitted to ICU.

This raised a question that whether there was an alternative to PHT, which can be used as effectively but more safely. On researching more, I came across LVT, which showed promising results in controlling the seizures and hence prompted me to review the evidence in its use in SE.

Three part Question:

In {adult patients with Status Epilepticus}, is {Levetiracetam a safe and effective second line anti-convulsant compared to Phenytoin}, in {terminating seizures}?

Literature Search:

Using the Athens interface (www.library.nhs.uk), I did a comprehensive literature search of MEDLINE (1946 to date), EMBASE (1980 to present), and CINAHL (1981 to present) databases, searching titles and abstracts, as well as index linking.The abstracts of the 247 unique papers were reviewed to ascertain if they answered the question, using the inclusion and exclusion criteria,this found 8 unique papers.There were 3 retrospective, 2 prospective, one systematic review,one meta analysis and one critical review.

These 8 papers have been critically appraised and reviewed. Levels of evidence have been graded as per the ‘Strengthening the Reporting of Observational studies in Epidemiology’ (STROBE) checklist (scored out of 22, Appendix 1), as well as the Scottish Intercollegiate Guidelines Network12 (SIGN - Appendix 2). 

Outcome and Conclusion:

All the studies had a clear objective, sound methodology and they showed promising results in terms of the outcome. The efficacy of LVT is comparable to PHT with less serious side effects, although the results were not statistically significant, p value >0.001.All the retrospective case series reported an efficacy between 61.8% to 94% for the use of LVT in SE,especially when used in elderly population with comorbidities,as supported by Z Yasiry9 et al, in their meta-analysis.

There is strong evidence to suggest that LVT is a safe and effective drug for its use in SE.The I/V formulation is still not licensed for use in SE, but the accumulating evidence in the literature suggests that the efficacy of LVT is comparable or even better than PHT.The use should be individualised as per the clinical need.

ESSTT30 and ECLIPSE29, are two promising RCT going on at present to compare the safety and efficacy of LVT.


Saurav BHARDWAJ (Birmingham, United Kingdom), Amit JAISWAL, Virupaksha SADHUNUVAR

Tuesday 15 October

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EPOSTER 4.2
10:45 - 11:05

ePoster 4.2 - Short Oral Presentation - Screen 2

Moderator: Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, Sweden)
10:45 - 10:50 #18228 - SP065 Decompressive craniectomy may not be effective for traumatic brain injury; A Nation-wide propensity score matching cohort study in Japan.
SP065 Decompressive craniectomy may not be effective for traumatic brain injury; A Nation-wide propensity score matching cohort study in Japan.

Background: Cerebral edema in traumatic brain injury can lead to cerebral herniation and result in disability or death. Decompressive craniectomy (DC) has been performed for the purpose of relieving elevated intracranial pressure with outcome improvement in severe TBI patients. However, there was little evidence whether DC was effective for outcome of TBI patients. We assessed the relationship between decompressive craniectomy for patients with severe traumatic brain injury and the prognosis using nation-wide hospital-based trauma registry in Japan.

Methods: Using Japanese Trauma Data Bank, we included severe traumatic brain injury patients whose head AIS scores were 3 and over and registered from 2004 to 2017 in this study. Multivariable logistic regression analysis and conditional logistic regression analysis were used to assess the association between decompressive craniectomy and the prognosis of traumatic brain injury patients after one-to-one propensity score matching for DC versus non-DC. The primary outcome was dead at hospital discharge.

Results: Among 69411 eligible patients with severe traumatic brain injury, 1523 patients (2.2%) received DC and 67888 patients (97.8%) did not receive DC. In the univariate analysis, the proportion of dead at discharge was higher in the DC group than the non-DC group (36.5% [556/1523] vs. 14.5% [9828/67888]). In the multivariate analysis, the DC group showed a more favorable survival outcome than the non-DC group (adjusted OR 0.294, 95% CI; 0.265-0.327). However, in the propensity-matched cohort, the DC group did not show a more favorable survival outcome than the non-DC group (68.7% [1045/1522] vs. 63.5% [967/1522], adjusted OR 0.787, 95% CI; 0.675-0.919).

Conclusion: Decompressive craniectomy may not be effective for patients with severe traumatic brain injury.


Yumi MITSUYAMA (Osaka, Japan), Yusuke KATAYAMA, Tetsuhisa KITAMURA, Nakagawa YUKO, Takeshi SHIMAZU
10:50 - 10:55 #18250 - SP066 Accuracy of TRISS and RISC II in predicting 30-day mortality in major trauma patients in Hong Kong: Retrospective cohort study.
SP066 Accuracy of TRISS and RISC II in predicting 30-day mortality in major trauma patients in Hong Kong: Retrospective cohort study.

Background:

Hong Kong has established an inclusive trauma system since the early 2000, and local trauma registries have been using TRISS methodology for audit and benchmarking purposes since its establishment. TraumaRegister DGU in Germany devised its own probability of survival model using data from its 900 trauma centres. RISC II was demonstrated to be superior to TRISS in Germany, and includes pre-trauma ASA, pupil size and reactivity, pre-hospital CPR and laboratory results including INR, base deficit and haemoglobin on top of those parameters used in TRISS. The aim is to compare the predictive ability of the probability of survival calculated using TRISS and RISC II for major trauma patients in Hong Kong.

 

Methods:

This was a retrospective cohort study using data from all five trauma centres in Hong Kong. Adult major trauma patients (ISS>15) from January 2013 to December 2015 were extracted from the five respective trauma registries. Parameters for TRISS was collected prospectively, and those extra data points in the RISC II scores were retrieved retrospectively. The primary outcome was the area under the ROC curve for TRISS and RISC II using the expected and observed 30-day mortality. Probabilities of survival (Ps) were derived by TRISS with MTOS coefficients and RISC II methodology. The Hosmer-Lemeshow goodness of fit test was used to test for the calibration of the model. Subgroups analyses investigated the performance of TRISS and RISC II for the mechanism of injury and age>80. Ethics approval has been obtained from the local review board.

 

Results:

1864 patients were recruited during the study period. 67.2% was male and the median age was 60 years old. The median ISS was 24, with 40% of patients with ISS over 25. Low fall was the most common mechanism of injury, with head and neck being the most commonly injured body region. The 30-day mortality was 22.4%. The expected mortality was 20.0% using TRISS and 19.7% from RISC II. The AUC was 84.8% (CI 82.7 to 86.9) and HL test 63.2 (p<0.001) for TRISS. RISC II yielded a superior AUC of 89.6% (CI 88.1 to 91.2) and HL test of 78.9 (p<0.001).

Subgroup analyses showed that both score performed worse for ISS 25 or above (AUC: TRISS 80.4%, RISC II 87.7%), age 80 or above (AUC: TRISS 80.6%, RISC II 82.9%), low falls (<2m) (AUC: TRISS 81.7%, RISC II 85.5%), and significant head or neck injury (AIS 3 or above) (AUC: TRISS 83.1%, RISC II 87.7%). RISC II had performed significantly better than TRISS for all subgroups, except in age 80 or above and low falls.

Conclusion:

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult trauma patients with ISS >15. RISC II also significantly better than TRISS in all subgroups, except in age 80 or above and low falls. These points should be taken note when performing future audit or benchmarking exercises.



This study did not receive any specific funding.
Dr Kevin Kc HUNG (Hong Kong, Hong Kong), Cosmos LAI, Janice Hh YEUNG, Marc MAEGELE, Colin A GRAHAM
10:55 - 11:00 #18899 - SP067 A retrospective analysis of tranexamic acid administration in the major trauma population conveyed to the Queen Elizabeth University Hospital, Glasgow.
SP067 A retrospective analysis of tranexamic acid administration in the major trauma population conveyed to the Queen Elizabeth University Hospital, Glasgow.

Background

NICE Major Trauma Guidelines, introduced in February 2016, support the administration of 1g bolus of tranexamic acid (TXA) within 3-hours in patients with major trauma and active or suspected bleeding, followed by a further 1g over 8-hours. This recommendation, based on evidence from the CRASH-2 trial, illustrated a significant time-dependent mortality benefit. The Queen Elizabeth University Hospital (QEUH), Glasgow, receives the majority of the West of Scotland’s major trauma and was identified as a site where appropriate administration of TXA could yield most benefit.

Aims

To assess those patients admitted to the QEUH, who were administered 1g TXA and whether this was within 3 hours of injury as per NICE guidelines. The second aim was to identify how many of these patients go on to have a second dose of TXA administered as an infusion over 8-hours when clinically indicated.

Methods

After review of supporting literature, a retrospective cohort study was designed. Study population included all trauma patients who were admitted to the QEUH and received TXA between 01/11/2017-28/08/2018.  Data concerning demographics and TXA administration were collected electronically from the trauma registry (eSTAG) and verified using electronic clinical records. Twenty-five secondary transfers were excluded as well as ten patients with insufficient data. Data is presented as a mean (standard deviation) or as a median (interquartile range) as appropriate.

Results

One hundred and fourteen patients were identified by eSTAG as having received TXA and were admitted to the QEUH. Of these, 79 patients were analysed and 35 were excluded. Seventy-three (92.4%) patients received their initial dose of TXA within 3 hours and 6 (7.6%) did not. Median time to first dose was 70 minutes (44-110 minutes). Only 1 (0.79%) patient received an incorrect dose of 200mg, all others received 1g.

Of the 79 patients, 9 received a second dose of TXA, 3 as an infusion. All second doses were given within 24 hours of the initial TXA dose, median time 115 minutes (65-162.5). One patient received a second dose of 800mg, the rest received 1g.

Discussion and Recommendations

In spite of current trial data demonstrating a significant reduction in mortality following use of TXA in major trauma with suspected bleeding, this study indicates that this has not yet been incorporated into clinical practice. This is especially true regarding administration of a second dose with only 9 patients receiving this dose and with none of these following the protocol outlined in the literature. One reason secondary dosing might be so low is that it may not be indicated if patients were found not to be actively bleeding. Not being able to verify those that had a clinical indication and those that did not is a limitation of the study.

With current evidence supporting administration of a secondary TXA dose further efforts should be made to encourage this through education of both pre-hospital and hospital practitioners. It should also be highlighted that first dosing of TXA after 3 hours has been associated with higher rates of mortality and should therefore be avoided.


Gage WILLOX, Dr Chase SCHULTZ-SWARTHFIGURE (Glasgow, United Kingdom), Hannah SMITH, Malcolm GORDON
11:00 - 11:05 #18992 - SP068 Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities.
SP068 Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities.

Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities. Authors: Saima Salman, Syed Ghazanfar Saleem, Qurat ul Ain Sheikh3, Kaniz Farwa Haider4, Megan Rybarczyk5, Zayed Yasin6, Lubna Samad7, Anna Q Yaffee8. CONFLICT OF INTEREST: No conflict of interest FUNDING: No external funding was sought for this research work ABSTRACT: Introduction: Structured trauma care has been proven in literature to improve patient outcome. Many organized systems are established across the globe to familiarize and train Emergency Physicians with basic and advance trauma care. The need is more pronounced in low and middle income countries (LMICs) where limited resources and poorly structured health care systems add to the challenges of trauma care with increase in morbidity and mortality. Characterization of epidemiology of trauma helps in identification of risk factors, injury severity and outcomes and establishes the baseline upon which interventions can be structured. Objective: To characterize the epidemiology of trauma patients presenting to the emergency department (ED) at The Indus Hospital (TIH) in Karachi, Pakistan including demographics, presenting Injury Severity Score (ISS), interventions and disposition. Methodology: One year Retrospective chart review of all poly-trauma patients older than 14 years from July 2017 to June 2018 presenting to TIH ED was conducted. Results: Out of 972 trauma patients presenting to TIH ED, 663 (68.2%) were males and 309 (31.7%) were females. Road traffic accidents were the most common mode of presentation with 766 patients (78.8%) followed by 121 falls (12.7%). Injury Severity score (ISS) was calculated upon arrival and 528 (54.3%) were found to be critically injured. All 365 discharged patients (100%) were moderately injured with scores of 9-15 and there was 100% mortality of the maximally injured nine patients with scores of 75. However, only 3.4% of these patients received a Focused Assessment Sonography in Trauma (FAST) ultrasound and none received further helical imaging of chest or abdomen. 90% received intravenous fluids but only 3.4% received a blood transfusion. Industrial trauma (p value 0.01) and falls (p value 0.007) were more common in men whereas burn victims were mostly women (p value 0.0001).  CONCLUSION: Given the unique position of TIH in terms of public-private partnership and philanthropy, the characterization of trauma patients presenting to TIH has strengthened our belief that patient outcomes can be improved through structured approach to trauma patients within the golden hour of trauma management through better inter specialty collaboration and lean utilization of resources. By identifying the gaps within patient management it is our hope that through interventions for capacity building, we will have a positive impact on patient outcome, specifically survival to discharge and stabilization/ diagnostic procedures received. KEY WORDS: Pakistan, Injury, Trauma, Injury Severity Score (ISS), Low and middle income countries (LMIC)


Dr Saima SALMAN (Karachi, Pakistan), Anna YAFFEE

Tuesday 15 October

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EPOSTER 4.3
10:45 - 11:05

ePoster 4.3 - Short Oral Presentation - Screen 3

Moderator: Anna SPITERI (Consultant) (Malta, Malta)
10:45 - 10:50 #18058 - SP069 Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department.
SP069 Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department.

Objectives We sought to estimate the prevalence of patients with cancer presenting to the emergency department (ED) who are undergoing treatment with immune checkpoint blockade (ICB) therapy; report their chief complaints; describe and estimate the prevalence of immune-related adverse events (IRAEs).

Methods Four abstractors reviewed the medical records of patients with cancer treated with ICB who presented to an ED in Paris, France between January 2012 and June 2017. Chief complaints, underlying malignancy and ICB characteristics, and the final diagnoses according to the emergency physician were recorded. Abstractors noted if an emergency physician identified that a patient was receiving an ICB and if the emergency physician considered the possibility of an IRAE. The gold standard as to whether an IRAE was the cause was the patients’ referring oncologist’s opinion that the ED symptoms were attributed to ICB and IRAE according to post-ED medical records. Descriptive statistics were reported.

Results Among the 409 patients treated with ICB at our institution, 139 presented to the ED. Chief complaints were fatigue (25.2%), fever (23%), vomiting (13.7%), diarrhoea (13.7%), dyspnoea (12.2%), abdominal pain (11.5%), confusion (8.6%) and headache (7.9%). Symptoms were due to IRAEs in 20 (14.4%) cases. The most frequent IRAEs were colitis (40%), endocrine toxicity (30%), hepatitis (25%) and pulmonary toxicity (5%). Patients with IRAEs compared with those without them more frequently had melanoma; had received more distinct courses of ICB treatment, an increased number of ICB medications and ICB cycles; and had a shorter time course since the last infusion of ICB. Emergency physicians considered the possibility of an IRAE in 24 (17.3%) of cases and diagnosed IRAE in 10 (50%) of those with later confirmed IRAE. IRAE was more likely to be missed when the referring oncologist was not contacted or when the patient had respiratory symptoms, fatigue or fever.

Conclusions ICB exposes patients to potentially severe IRAEs. Emergency physicians must identify patients treated with ICB and consider their toxicity when patients present to the ED with symptoms compatible with IRAEs.


Olivier PEYRONY (Paris), Yoann TIEGHEM, Jessica FRANCHITTI, Sami ELLOUZE, Ivonne MORRA, Isabelle MADELAINE-CHAMBRIN, Remi FLICOTEAUX, Barouyr BAROUDJIAN, Elie AZOULAY, Sylvie CHEVRET, Jean-Paul FONTAINE
10:50 - 10:55 #18346 - SP070 High-fidelity simulation versus low-fidelity simulation training for physicians’ cardiopulmonary resuscitation training: A systematic review and meta-analysis.
SP070 High-fidelity simulation versus low-fidelity simulation training for physicians’ cardiopulmonary resuscitation training: A systematic review and meta-analysis.

BackgroundHigh –fidelity resuscitation training is near to become the gold standard for training physicians on cardiopulmonary resuscitation techniques. Nevertheless, its effectiveness remains unknown.

ObjectiveThe objective of this study is to identify and synthesise the best available evidence for the effectiveness of high versus low fidelity simulation in physicians’ resuscitation training.

Data source-A systematic search of Pubmed and Embase was conducted considering the period from 1stJanuary 2008 to 31stDecember 2017.

Study selection-The research manuscripts evaluating High-fidelity simulation compared with low-fidelity in the training of physicians for CPR were considered for analysis.

Data extraction-Outcomes including written tests results, megacode scoring and other cardiopulmonary resuscitation (CPR) performance assessments were evaluated. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome. A fixed effect model was used, assuming standard mean as the effect measure.

Results-545 papers were eligible from the literature search and 17 were included in the analysis (16 RCT’s and one paired cohort study). Meta-analysis of skills performance evaluationusing megacode scoring evidenced a moderate benefit for High-fidelity simulation training when compared with low fidelity programs [SMD 0.54; 95% CI −0.36 to 0.73]. Similarly, written test results were better for High-fidelity simulation learners than for low fidelity simulation trainees [SMD 0.47; 95% CI 0.21 to 0.73]. Time to first compression favored adding some experimental intervention to High-fidelity simulation instead of High-fidelity alone [SMD 0.53; 95% CI 0.39 to 0.68]. 

Conclusion-The training of physicians on CPR with the use of High-fidelity simulation programs results in best technical and non-technical skills performances and increases theoretical knowledge.



PROSPERO 2018 CRD42018086699
Dr Claudia FEBRA (Lisboa, Portugal), Sandra PAIS, Ana MACEDO
10:55 - 11:00 #19054 - SP071 Anaphylaxis in an emergency department: Epidemiology, clinical features and management.
SP071 Anaphylaxis in an emergency department: Epidemiology, clinical features and management.

Background:

The rate of occurrence of anaphylaxis is increasing in the Emergency Department (ED).

Understanding potential triggers and patient-specific risk factors for severity and fatality is the key to performing appropriate risk assessment in those who have previously experienced an acute anaphylactic episode.

Objective:  

To describe the epidemiology, clinical features, management and outcome of patients with anaphylaxis in ED.

Methods:

Prospective, monocentric study over six years. Inclusion criteria: patients aged over 14 years presenting consecutively to ED with the diagnosis of anaphylaxis. Collection of epidemiological, clinical and therapeutic parameters.

Results:

A total of 687 patients were included. The mean age was 40 ±15years. Sex ratio=0,74.A history of anaphylaxis was reported in 40 % of cases. Cutaneous features were present in 96% of patients. Respiratory, cardiovascular, gastrointestinal and neurologic features were found respectively in 27, 22, 16 and 2%. Causative agent was known in 84% of cases. Most common category of causes n (%): drugs 363 (52,8%), food 170(24,7%) and insects 37(5,4%). No causes were apparent in 16,2% of cases. An anaphylactic shock was recorded in 336 patients (49%). Five factors were identified to be predictive for anaphylactic shock occurrence: history of anaphylaxis, anaphylaxis induced by antibiotics, parenteral administration, neurologic features and time elapsed between symptoms onset and the first medical contact equal to one hour. Adrenaline was used in 42%of patients, intravenously in 16,2%,via a breathing mask in 177 patients (25,8%).Fluid resuscitation was given to 610patients(89%).409 patients (59,5%) received histamine H1 antagonist, 658 patients (95,8%) received corticosteroids. 86%  of patients were discharged directly from ED after a mean period of observation of 5 hours. Biphasic reactions were reported in 13 patients. There was no death cases registered. Patients with drugs anaphylaxis were all referred to the allergy clinic.

Conclusion :

Anaphylaxis requires prompt recognition and management to improve patient outcomes.


Raja FADHEL, Emna REZGUI, Ines CHERMITI, Syrine KESKES, Sawsen CHIBOUB, Monia NGACH, Sana TABIB (ben arous, Tunisia), Sami SOUISSI, Hanen GHAZALI
11:00 - 11:05 #19380 - SP072 Clinical manifestations of cocaine exposure in the pediatric emergency department.
SP072 Clinical manifestations of cocaine exposure in the pediatric emergency department.

Background: In the last decades, substance abuse has been mostly steady, with the exception of a significant increase in cannabinoids and cocaine circulation. From a clinical point of view, emergency department (ED) clinicians may evaluate substance abusers for a wide variety of symptoms. While adults and adolescents usually come to the ED with well-known clinical manifestations, no studies have thoroughly investigated how passive cocaine exposure might reveal itself in younger children.

Objectives: The aim of the study was to investigate the prevalence and describe presenting complaints and clinical manifestations of unsuspected exposure to cocaine in children attending to the pediatric ED.

Methods: We performed a retrospective study of children below 16 years of age evaluated in the ED of a tertiary care Pediatric Hospital of Padua, Italy, in 2018. Children were included if they received urine or blood toxicology screenings, in absence of a clear history of cocaine exposure.

Results: 102 children under 16 years underwent toxicology screening after evaluation in our Pediatric ED, 13 children showed positivity of urine or blood screening. Of these, 12 had confirmation of cocaine exposure by second-level analyses. Three were evaluated for signs and symptoms compatible with a first episode of absence epilepsy [Odds Ratio (OR) of cocaine exposure in these patients = 14.7, 95% confidence interval (CI) 2.16-99.7, p<0.05]. Other signs such as first convulsive episodes [OR = 1.44, 95% CI 0.35-5.87], tachycardia [OR = 2.52, 95% CI 0.58-10.94] or irritability [OR = 2.04, 95% CI 0.61-6.9] showed no correlation with confirmed cocaine exposure. All 13 patients were hospitalized, nine (69%) resulted positive for other substances, the most frequent being cannabinoids. Ten patients had dysfunctional family dynamics that would mostly surface during hospitalization, and were not investigated in the ED history-taking.

Conclusion: With the increase in cocaine abuse among adults, the risk of transfer to children is also increasing. Unfortunately, no single sign and symptom can be used to accurately identify children who have been exposed to cocaine. Toxicology screens may be useful for children presenting to the ED with suspicion of absence epilepsy. Clinicians should consider cocaine exposure in infants and children presenting with non-specific signs and symptoms, seizures or movement disorders. Larger studies will be needed to develop a prediction model of cocaine exposure in childhood.



No funding was secured for this study
Dr Lorenzo ZANETTO (Padova, Italy), Federica DAL PIVA, Melissa ROSA-RIZZOTTO, Silvia BRESSAN, Masiero SUSANNA, Deborah SNIJDERS

Tuesday 15 October

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EPOSTER 4.4
10:45 - 11:05

ePoster 4.4- Short Oral Presentation - Screen 4

Moderator: Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)
10:45 - 10:50 #17926 - SP073 A new risk assessment model for the stratification of the thromboembolism risk in medical patients.
SP073 A new risk assessment model for the stratification of the thromboembolism risk in medical patients.

BACKGROUND: In hospitalized medical patients, the venous thromboembolism (VTE) risk is notable. Nevertheless, the available assessment model (TPF) is generally underused. In this work, we propose an ex novo risk assessment model based on the elaboration of the clinical data exhibited by the VET patients. Differently from previous studies, the proposed approach does not exploit pre-established models, resulting in a more valid and easy-to-use score.
METHODS: We performed a double case-control observational study. For each case of VTE, we enrolled two consecutive patients without VTE of equal sex and age group.
RESULTS: We analyzed the data of 1215 patients, 409 with VTE and 806 case-control. 365 patients (30%) were in charge to the EM department, while 850 patients (70%) to the IM one. The VTE risk factors with more statistical significance (P<0.01) are: previous VTE, active cancer, known thrombophilic condition, immobilization, chronic venous insufficiency, hyperhomocysteinemia, central venous catheter, recent hospitalization. Obesity, recent surgery, family history of VTE, hormone therapy and treatment with drugs that stimulate hematopoiesis are resulted at intermediate statistical significance (P<0.05 but >0.01). A multiple logistic regression was used with robust standard errors and forward selection of the candidate variables using the Bayesian information criterion. A new score is developed, the “TEVere Score”, which shows a higher specificity and sensitivity (respectively 43.3 and 87.5, with accuracy 72.1) compared with the Padua, the Kuscer and the Chopard Score. TEVere Score also exhibits a greater predictive validity for thromboembolism risk (AUROC 0.7266; 95% CI: 0.71 to 0.73) than the Kuscer Score (AUROC 0.6891; 95% CI: 0.67 to 0.70) (P=0.0093).
CONCLUSIONS: The TEVere Score has proven to exhibit a higher accuracy than the other scores commonly used in clinical practice to stratify the thromboembolism risk.



The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Informed consent was obtained from all the subjects or their relatives. The protocol was approved by the Fatebenefratelli Hospital Ethics Committee
Giovanni Maria VINCENTELLI, Sergio TIMPONE, Giuseppe MURDOLO (perugia, Italy), Igino FUSCO MOFFA, Paolo Diego L'ANGIOCOLA, Francesco BORGOGNONI, Manuel MONTI
10:50 - 10:55 #18042 - SP074 High-sensitivity cardiac troponin T 30-day all-cause mortality in patients with acute heart failure. A propensity score-matching analysis based on the EAHFE registry. EAHFE-TROPICA 4 Study.
SP074 High-sensitivity cardiac troponin T 30-day all-cause mortality in patients with acute heart failure. A propensity score-matching analysis based on the EAHFE registry. EAHFE-TROPICA 4 Study.

Background: Acute heart failure (AHF) patients with high levels of troponin have a worse prognosis. High-sensitive troponin T (hs-TnT) has been used as a tool to stratify prognosis in many scales but always as a qualitative variable, not as a quantitative one.

Objectives: The main objective of this study is to determine a cut-off for hs-TnT with an elevated  negative predictive value (NPV) for 30-day all-cause mortality.

Methods: We analyzed the EAHFE registry, a prospective follow-up cohort of patients with AHF. A propensity score analysis of the optimal hs-TnT cut-off point was performed, previously determined by a receiver operating characteristic (ROC) curve analysis.

Results: Of the 13791 patients in the EAHFE cohort, we analyzed 3190 patients in whom hs-TnT determination was available. The area under the ROC curve for 30-day all-cause mortality was 0.70 (95%CI 0.68 to 0.71; p < 0.001) and established an optimal cut-off of hs-TnT of 35 ng/L. The sensitivity and specificity for this cut-off were 76.2 and 55.5%, respectively, with a NPV of 95.3%. Thirty-four variables showed differences based on the cut-off of 35 ng/L for hs-TnT and a propensity score was made with them. A greater mortality at 30 days was shown in patients with hs-TnT > 35 ng/L in the analysis of the population obtained with the propensity score, with a HR of 2.95 (CI95% 1.83 – 4.75; p < 0.001).

Conclusions: A hs-TnT value of 35 ng/L is an adequate cut-off point to evaluate 30-day all-cause mortality with a NPV of  95.3%


Dr Alex ROSET (Barcelona, Spain), Marco CORDERO, Carles FERRÉ, Ferran LLOPIS, Ignasi BARDÉS, Javier JACOB
10:55 - 11:00 #18464 - SP075 Acute hemodynamic effects of digoxin in patients with congestive heart failure.
SP075 Acute hemodynamic effects of digoxin in patients with congestive heart failure.

 

Introduction:

Digoxin was the cornerstone of heart failure therapy for decades due to its positive inotropic and neuro-hormonal modulation properties until the change of paradigm in heart failure pathophysiology. Our study evaluates outcomes stratified by heart function status in patients with heart failure treated with digoxin.

Materials and methods:

This is a prospective randomized ,  double blind ,placebo controlled parallel group multicenter clinical trial  . We randomly assigned  patients with  heart failure to treatment with digoxin or placebo(median dose of digoxin  is 0.25 mg per day). The effects of each one on hemodynamic parameters : systolic time interval , cardiac output , left ventricular ejection fraction and BNP level were compared during a period of 48 hours , double –blind trial  ,performed at the emergency unit of Fattouma Bourguiba hospital in Monastir over a period of four  years( 2016-2017-2018-2019).We also aimed to compare the risk of mortality and  hospital stay time with digoxin use versus no digoxin in patients with heart failure. The diagnosis of heart failure was based on current or previous symptoms such as dyspnea, radiologic or echo graphic evidence of pulmonary congestion ,BNP level > 350 pg / ml or  NT proBNP > 1400 pg/ml.  Participants were excluded if they already received digoxin as a background treatment. Those who had a pacemaker or suffered from severe renal impairment (creatinine clearance of less than 30 ml/min) were also excluded.

Results :

We have been collecting during 2016,2017,2018 and 2019 ,  cases of patients with heart failure and only 438 of them have met eligibility criteria  : 104 of them have received digoxin while 229 of them did not.

In our study ,  both groups had comparable demographic characteristics .There was no significant difference between the two groups ,in terms of age , sex or NYHA functional classification .

The increase of cardiac output within two days : 11.35 % in the group treated with digoxin ,7.75 % in the other group (without significant difference).
The increase of the systolic ejection fraction : 7.39 % in the group treated with digoxin ,2 % in the other group. The difference between both results appear to be significant

Systolic time intervals: pre-ejection period  decreased by 12.67 % in the group treated with digoxin ,1.01 % in the other group (the difference was highly significant)

( p= 0.02). Left ventricle ejection time  increased by  0.82 % in the digoxin group , 0.2 % in the other group . The difference was estimated to amount to 0.037.

  ED length of stay in the digoxin group : 6.67 days , 10 days  in the placebo group . The difference between the two was significantly high (p = 0.019). Death rate in the hospital : 1 % in the digoxin group and 0 % in the other group . The difference was not significant (p=0.78 ).

 Conclusion In patients with acute heart failure  , short course digoxin is  associated with an improvement of  heart function parameters  and decrease of hospital length of stay.

 

 


Asma KHALFALLAH (Mahdia, Tunisia), Amel MARSIT, Adel SEKMA, Mohamed Amine MSOLLI, Kaouther BELTAIF, Hamdi BOUBAKER, Semir NOUIRA
11:00 - 11:05 #19062 - SP076 The sum of st segment depression and severity of coronary artery disease in non-st segment elevation acute coronary syndrome.
SP076 The sum of st segment depression and severity of coronary artery disease in non-st segment elevation acute coronary syndrome.

Background: The electrocardiogram (ECG) remains central in the risk stratification of non ST-segment elevation acute coronary syndrome (NSTEMI). The ST segment depression appears to be the most predictive marker of mortality at day 30 and at one year. Recently, many studies had demonstrated that the sum of ST-segment depression provides much more information than the simple qualitative assessment of ST-segment depression>0.5 mm.

Objective: To find out the association between the sum of magnitude of ST segment depression and angiographic severity in NSTEMI patients.

Methods: A prospective observational study was conducted over six years. Patients with the diagnosis of NSTEMI and an ST segment depression > 0.5 millimeters (mm) in at least one lead were included. ST segment depression was measured and the cumulative sum of the ST-segment depression, in mm was calculated. The location, the number of leads with ST segment depression was also measured in all ECG leads. The prognosis was based on the evaluation of major adverse cardiac event (MACE) at six months.

Angiographic severity was assessed by a validated vessel score. The sum of the magnitude of ST segment depression was correlated with angiographic severity of coronary artery disease.

Results: Inclusion of 287 patients. Mean age was 62±11 years. Sex ratio = 1.7. Comorbidities (%): hypertension (59), diabetes (45), dyslipidemia (33), coronary artery disease (28). Mean sum of ST segment depression was 5 [1,28].

Mean delay of door to balloon = 4 hours [1, 72]. Twenty seven percent of patients developed a MACE.  In multivariate analysis a cumulative sum of ST-segment depression > 7 mm (adjusted OR = 5.34, p <0.001, 95% CI [2.71 to 10.51]) was independently associated with MACE at six months.

Positive correlation was found between the sum of ST segment depression, the number of leads with ST segment depression and the severity of coronary artery disease with (r=0.352; p<0.0,1) and (r= 0.361; p<0.001) respectively. 

Conclusion: This study shows that the sum of ST segment depression in all ECG leads is a powerful predictor of severity of coronary artery disease.

 


Hela BEN TURKIA (Ben Arous, Tunisia), Syrine KESKES, Wided BAHRIA, Ines CHERMITI, Mahbouba CHKIR, Sami SOUISSI, Hanen GHAZALI, Jamila HABLI, Souad CHKIR

Tuesday 15 October

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EPOSTER 4.5
10:45 - 11:05

ePoster 4.5 - Short Oral Presentation - Screen 5

Moderator: Marc SABBE (Medical staff member) (Leuven, Belgium)
10:45 - 10:50 #18497 - SP077 New infant chest compression technique. A randomized, crossover, simulation trial.
SP077 New infant chest compression technique. A randomized, crossover, simulation trial.

Background:

The ability to perform high quality chest compressions is one of the basic skills that medical staff should have. Current CPR guidelines recommend performing chest compression in infants and newborns using either two fingers (TFT) or two thumbs (TTHT). However, both have their advantages and disadvantages. In the first case, as shown by the studies, there is full chest recoil, however, the chest is pressed too shallow, in the second case the results are the opposite. The aim of the study was to compare these two methods with the authors' own new method of chest compression. 

Methods:

This was prospective, randomized, crossover, observational, simulation trial. The study involved 60 nurses who participated in Basic Life Support trainings. After the correct demonstration of the recommended compression methods (TFT and TTHT) and the innovative chest compression method (nTTT) based on thumbs perpendicular to the chest,  the participants had the opportunity to practice individual methods with the use of an infant simulator. During the study, participants were asked to perform 2-minute neonatal resuscitation based on continuous chest compression. Both the sequence of participants and methods of chest compression were random and ResearchRandomizer was used for this purpose. The study analyzed the depth and rate of chest compression as well as the correctness of chest recoil.

Results:

The study involved 60 nurses whose median age was 43 years (IQR; 32-48), and work experience achieved 17 years (IQR; 5-25). The median depth of chest compression based on particular compression techniques (TFT, TTHT, nTTT) was differentiated and achieved 32 mm (29-35) vs. 41 mm (37-42) vs. 40 mm (37-42; p<0.001) respectively. The rate of compression was the highest for TFT and was 127 (118-130) compressions per minute (CPM), followed by 115 CPM (108-122) and 112 CPM (102-120; p<0.001) for TTHT and nTTT (102-120; p<0.001), respectively. Correctness of chest recoil was 96% (83-100) for TFT, 35% (29-43) for TTHT, and 96% (89-100) for nTTT.

Discussion and Conclusions:

The results of the study show that the nurses participating in the study performed the highest quality chest compressions on the newborn using the new authors method of chest compression nTTT. Further research is needed to verify the results obtained in the study. 



own research carried out financed from the statutory resources of the Lazarski University
Szarpak LUKASZ, Smereka JACEK (Wroclaw, Poland), Gorczyca DAMIAN, Evrin TOGAY, Plusa TADEUSZ, Katipoglu BURAK
10:50 - 10:55 #18711 - SP078 Interactive effect of multi-tier response and advanced airway on good neurological recovery after out-of-hospital cardiac arrest.
SP078 Interactive effect of multi-tier response and advanced airway on good neurological recovery after out-of-hospital cardiac arrest.

OBJECTIVES: High-quality CPR including early defibrillation, uninterrupted chest compression and optimal airway management are primary components associated with return of spontaneous circulation (ROSC) and preventing neurological impairment. We hypothesized that the multi-tier response will provide higher quality of CPR including airway management, but the type of combination will make different interaction to the airway management for outcomes after OHCA. The aim of this study was to determine the effect of advanced airway management method on outcomes and compare the effect size across the multi-tier response type on outcomes after OHCA.

METHODS: This study was a retrospective and observational cohort study utilizing the Korea OHCA Registry (KOHCAR), which included all adult EMS-assessed OHCA patients with presumed cardiac etiology. The study period was from January 2015 to December 2017. Airway management methods were categorized into the endotracheal intubation (ETI) group and supraglottic airway (SGA) group. Tier system were divided into single-tier response and two types of multi-tier response (MTR) including an ambulance-ambulance multi-tier response (ATR) and an ambulance fire engine multi-tier response (FTR). Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to show the association between airway management/tier type and patients with ROSC rate, survival to discharge rate and neurological outcomes. Multivariable logistic regression analysis performed to assess the interaction effects of airway management method and tier type.

RESULTS: Among 87,551 EMS-assessed OHCAs during the study period, a total of 25,888 patients were analyzed. In comparison of single-tier response and MTR type, ATR was significantly associated with higher ROSC rate, survival to discharge and neurologic outcomes than single-tier response. However, there was no significance difference between FTR and single-tier response. Interaction analysis shows that regardless of tier type, SGA was significantly lower ROSC rate than ETI.

CONCLUSION: In this nationwide observational cohort study, we observed that ATR provide good clinical outcomes than single-tier response or FTR. And regardless of tier system, SGA showed significantly lower ROSC rate than ETI. The indeterminate evidence of optimum airway management and tier type for OHCA has encouraged calls for randomized controlled trials to clarify precise circumstances, patients’ conditions and characteristic of the EMS system and survival outcomes.


Dr Hyouk Jae LIM (Seoul, Korea, Republic of), Joo JEONG, Kihong KIM, Jungeun KIM, Young Sun RO, Sang Do SHIN
10:55 - 11:00 #19132 - SP079 The Prognostic Value of Pulse Oximetry (POP) Waveform During Cardiopulmonary Resuscitation.
SP079 The Prognostic Value of Pulse Oximetry (POP) Waveform During Cardiopulmonary Resuscitation.

Background and Objectives
Quality of cardiopulmonary resuscitation(CPR) is associated substantially with the mortality and morbidity of cardiac arrest patients. However, there is little technology available to provide non-invasive real-time feedback on the effectiveness of CPR. Blood Oxygen Saturation (SpO2) waveform is associated with intention, frequency, and interruption of chest compression. In this study, we tend to examine whether finger pulse oximeter plethysmograph(POP) waveform can be used to monitoring the effectiveness of CPR.
Methods
This was a prospective multicenter observational study that includes emergency departments from 14 teaching hospitals in China from 2013 - 2014. All patients with out of hospital cardiac arrest (OHCA) were enrolled in this study. Patients who enrolled were resuscitated according to 2010 AHA CPR guideline. Demographic information, ECG, pulse oxygen saturation, PetCO2 during CPR was collected. The area under the POP curve (AUCp) and amplitude of the curve (Amp) was recorded and analyzed between those with and without return of spontaneous circulation (ROSC). Furthermore, predictive value was also compared between POP curve and PetCO2.

Results
617 OHCA patients were admitted during the period of our study, among them, 400 were finally enrolled. 102 patients got ROSC in the emergency departments while 298 patients without. Among patients with ROSC AUCp, Amp, and PetCO2 was significantly higher compared to those without ROSC (all p<0.05). Both AUCp and Amp had good correlation with PetCO2. In addition, cutoff value of AUCp> 2726 PVPG and Amp>58 PVA had a predictive value of ROSC with a sensitivity of 0.81 and 0.80, specificity of 0.67 and 0.68 respectively. On the other hand, PetCO2 in our study with cutoff value of 14.5mmHg had a sensitivity of 0.676 and specificity of 0.565 to predict ROSC.
Conclusions
POP may be used as a novel method for feedback of the effectiveness of CPR.

Yu XUEZHONG, Xu JUN (Beijing, China), Jin KUI
11:00 - 11:05 #19234 - SP080 Point-of-care Ultrasound role in the modern Emergency Physician’s practice in Romania.
SP080 Point-of-care Ultrasound role in the modern Emergency Physician’s practice in Romania.

BACKGROUND:

Point-of-care ultrasound (POCUS) offers additive value in the diagnosis and treatment of emergency and/or critically ill patients. To help spread this medical practice in Romania within the nonradiologist community, under EUSEM guidance we conducted a POCUS course. The course was done in a single major university medical centre of Romania under the guidance of established POCUS faculty.

OBJECTIVE:

Our aim was to characterize the current practice of emergency physician and the effect of the POCUS course on the practice of junior, registrar and consultant level doctors that had no or not enough previous ultrasound (US) experience.

METHODS:

A 11-question anonymous survey was emailed to 40 graduates over a 4-week period, before the course and 2 months after attending.  All the participants had as their primary speciality Emergency Medicine.

No incentives were provided for completion of the questionnaire. Descriptive statistics are reported.

RESULTS:

A total of 21 participants completed the study for a response rate of 52.5%.

For the vast majority of them, this was the first ultrasonography course they attended, but 28.7% attended an US course previously.

 

Out of the doctors that completed the questionnaire 66,66 % were registrars, 28,58% consultants and just 4,76% junior doctors. Interesting note is the fact that although without previous formal training 71,42% were already using US in their practice, this percentage increasing to 100% after attending the course. Those that used US in their daily practice used it quite rarely, 47,61% reporting using it less than 2 times per month, justifying this due to lack of time (66,66%) but also lack of legislation to support them (28,57%). 33.33% of the participants also named the lack of trust of other specialities as an important discouragement. The main situations in which US was used in the ED was to check for cardiac activity in PEA (76,19%), detecting free intraabdominal fluid in trauma (57,14%) and facilitating invasive procedures such as central venous access and pleural taps. A majority also used POCUS to guide them in the ALS protocols especially in reversible cases such as hypothermia and cardiac tamponade but also in making decisions to stop resuscitation.

The second questionnaire showed an increase in US usage in the ED but the users did not rely on their findings and requested second opinions in severe cases.

 

CONCLUSION: The analysis shows that the interest in POCUS, especially in the Emergency Department, is quite high in Romania. This tendency is more common in the younger generation of doctors (juniors and registrars) who prefer to use it in answering quick FAST questions but also aiding in making tough ALS/ATLS protocol decisions and in invasive procedures. Further similar undertakings will probably open ground for more US based protocols making this practice more common in Romania and Easter European countries.

Emergency ultrasound should be introduced into an emergency medical service area as a diagnostic modality that provides benefits to patients. Emergency physicians have to be specifically trained and to participate in continuous education activities.


Catalin BOUROS, Mihaela CORLADE, Ovidiu Tudor POPA, Paul NEDELEA, Andrei HANCU, Gabriela GRIGORAS, Anca HAISAN, Diana CIMPOESU (IASI, Romania)
11:10

Tuesday 15 October

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A32
11:10 - 12:40

Airway
Beyond the Larynx: Airway management from the A team
Airway, HOT TOPIC SPEAKER!

Moderators: Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany), Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA)
11:10 - 12:40 Psychology in the difficult airway. Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany)
11:10 - 12:40 HOT TOPIC SPEAK! Alternatives to RSI: Contemporary Airway Management with Ketamine. Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA)
11:10 - 12:40 If Carlsberg did… RSIs. Dr Clare BOSANKO (EM/PHEM) (Plymouth, UK, United Kingdom)
CONGRESS HALL

Tuesday 15 October

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B32
11:10 - 12:40

Disaster medicine
Mass casualty triage: panel discussion
Disaster medicine, INTERACTIVE SESSION, Pre Hospital

Moderators: Massimo AZZARETTO (Associate Researcher) (NOVARA, Italy), Dr Abdo KHOURY (PRATICIEN HOSPITALIER) (Besançon, France), Luca RAGAZZONI (Scientific Coordinator) (Novara, Italy)

11:10 - 12:40 Prehospital. Riccardo STUCCHI (Anesthetist Intensivist - Referent for MCI-MGE) (Milan, Italy)
11:10 - 12:40 Emergency Department. Dr Eric WEINSTEIN (Disaster Medicine Researcher) (Summerville SC, USA)
11:10 - 12:40 Humanitarian Setting. Laura ARCHER (Senior Officer, Emergency Medical Services) (Geneva, Switzerland)
FORUM HALL

Tuesday 15 October

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C32
11:10 - 12:40

Late breaking research
Research

Moderator: Barbra BACKUS (Emergency Physician) (Rotterdam, The Netherlands)
11:10 - 12:40 TXA in epistaxis. Adam REUBEN (EuSEM) (Exeter, United Kingdom)
11:10 - 12:40 New tools in the early diagnosis of acute coronary syndromes. Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom)
11:10 - 12:40 Sterile vs non-sterile sutures for wounds in the ED. Wouter RAVEN (Emergency Physician) (Leiden, The Netherlands)
SOUTH HALL 3AB

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D32
11:10 - 12:40

YEMD - Nightmares in ED
Your role models are telling their personal horror stories
Young Emergency Medecine

Moderator: Martin FANDLER (Consultant) (Bamberg, Germany, Germany)
Speakers: Simon CARLEY (Consultant in Emergency Medicine) (Manchester), Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, Canada), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
SOUTH HALL 3C

Tuesday 15 October

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E32
11:10 - 12:40

NURSES
Emergency nursing education
Education, Nurses

Moderators: Tessa POSTUMA (Trainer) (DOETINCHEM, The Netherlands), Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, The Netherlands)
11:10 - 12:40 Advanced Practice Nursing in Emergency Care. Bart HUYBRECHTS (Nurse practitioner) (Amsterdam, The Netherlands)
11:10 - 12:40 What last years literature learned us about: ED nursing education. Dr Thordis K. THORSTEINSDOTTIR (Professor) (Reykjavik, Iceland)
11:10 - 12:40 What last years literature learned uw about: simulation as an educational intervention. Thorsteinn JONSSON (RN, MS) (Reykjavik, Iceland)
CHAMBER HALL

Tuesday 15 October

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F32
11:10 - 12:40

ABSTRACTS SESSION

Moderators: Roberta PETRINO (Head of department) (Italie, Italy), Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
11:10 - 11:20 #18300 - OP073 The feasibility and effectiveness of "e;Hour-1 Bundle"e; sepsis treatment in the emergency room: a retrospective before-after study.
OP073 The feasibility and effectiveness of "e;Hour-1 Bundle"e; sepsis treatment in the emergency room: a retrospective before-after study.

Background. In 2018, “Hour-1 Bundle” was proposed by The Surviving Sepsis Campaign group. It encourages clinicians to complete initial treatment of sepsis and septic shock within 1 hour. However, there is controversy about its feasibility and effectiveness. 

Methods. This is a retrospective before-after study conducted at an emergency room (ER) in Kobe City General hospital from September 2017 to April 2019. Five elements of Hour-1 Bundle (measure lactate level, obtain blood cultures before administering antibiotics, administer broad-spectrum antibiotics, begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L, apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg) were introduced by installing a timer in the ER, putting up original posters, providing short lectures about the bundle to staff members. We compared the outcomes and the compliance rates for the entire 1h bundle elements of consecutive suspected sepsis or septic shock patients treated in the ER and admitted to the ICU during 5 months after implementation of bundle (implementation group, from December 2018 to April 2019) with a control group treated during 6 months before the implementation group (from September 2017 to March 2018). The primary outcome was in-hospital mortality and the secondary outcome was the compliance rates for entire Hour-1 Bundle elements. Statistically significant differences were evaluated by chi-square test or Mann-Whitney U-test. P value < 0.05 was considered significant.

Results. There were 61, 65 patients in the control group and the implementation group with mean ages were 78 (IQR 65-83), 75 (67-85) years old, respectively. Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 8(IQR 5-11), and 9(IQR 5-12), respectively. The compliance rates for the entire Hour-1 Bundle elements were 16% in the control group and 40% in the implementation group (p<0.05). In-hospital mortality was 28% in the control group and 40% in the implementation group (p=0.15). Infectious diseases were ruled out in 33% of the control group and 18% of the implementation group after admission based on microbiological investigations and clinical courses. The compliance rates for the conventional 3-hour bundle in the control group and in the implementation group were 70%, 91%, respectively.

Discussions and Conclusions. By introducing Hour-1 bundle to the ER, the compliance rates for the bundle significantly improved. However, it was difficult to make a definite diagnosis of sepsis or septic shock within 1 hour at the ER. No significant reduction of in-hospital mortality was observed. Implementation of novel Hour-1 Bundle in the ER was still difficult and may not improve outcomes of the sepsis or septic shock patients.



This trial was approved by research ethics committee at Kobe City General Hospital (no. zn190514). No funding.
Akira SASAKI (Kobe, Japan), Machi YANAI, Koichi ARIYOSHI
11:20 - 11:30 #18315 - OP074 Artificial intelligence outperforms early warning scores at detecting sepsis: a retrospective Danish study.
OP074 Artificial intelligence outperforms early warning scores at detecting sepsis: a retrospective Danish study.

Background:

Sepsis is a life-threatening condition, and it is essential that the healthcare system quickly identifies patients and treats them adequately. Unfortunately, the early detection of sepsis remains a challenging problem, and even experienced physicians have difficulties in detecting sepsis early and accurately. We aimed to develop an Artificial Intelligence-based Early Warning Score System (AI-EWS) for the early detection of sepsis that is better than the currently used Modified Early Warning Scores (MEWS) and Sequential Organ Failure Assessment (SOFA).

Methods:

In this register study, we included health data from the years 2010 to 2017 on all citizens 18 years or older with residency in one of four Danish municipalities (Odder, Hedensted, Skanderborg, and Horsens). All relevant hospital contacts from multiple hospitals within the region were identified by the unique national social security system number (1,002,450 contacts). 754,179 non-acute outpatient contacts and 89,202 inpatient contacts with a duration of less than six hours were removed. 134,983 contacts with no episodes of suspected infection were removed leaving 24,076 inpatient contacts included for analysis. After inclusion each inpatient contact underwent a binary classification process to denote them as either sepsis-positive or sepsis-negative. The classification was made based on patients meeting the gold standard for sepsis based on the Third International Consensus Definitions for Sepsis (Sepsis-3). 1,635 (6.8%) inpatient contacts were classified as sepsis positive. We included data about biochemical blood tests, vital signs and glasgow coma scores from the electronic health record.

We developed the AI-EWS early sepsis detection model as a deep neural network composed of an embedding layer followed by a temporal convolutional network (TCN). The TCN has four temporal blocks, each with 540 filters of kernel size 10. The dilation rate of the convolutional filters was exponentially increased for each of the stacked temporal blocks. The AI-EWS was trained using Adam optimization, with a learning rate of 0.0005 and a batch size of 200.

The AI-EWS was validated using 5-fold cross-validation. As comparative measures, we used the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). The model was compared with TOKS (Tidlig Opsporing af Kritisk Sygdom), a Danish MEWS variant, and SOFA.

Results:

The following results are reported three, six, and twelve hours before sepsis with mean values and 95% confidence intervals. AI-EWS: (AUROC: 0.88(0.85;0.91), 0.83(0.79;0.87), 0.82(0.79;0.87); AUPRC: 0.41(0.40;0.43), 0.37(0.34-0.39), 0.30(0.26;0.33)), SOFA: (AUROC: 0.77(0.74;0.79), 0.73(0.71;0.74), 0.70(0.65;0-75); AUPRC 0.18(0.16;0.19), 0.16(0.15;0.18), 0.13(0.11;0.16)), and TOKS: (AUROC: 0.68(0.67;0.70), 0.59(0.58;0.59), 0.57(0.55;0.58); AUPRC: 0.12(0.10;0.14), 0.09(0.07;0.10), 0.10(0.09;0.10)). Furthermore, the AI-EWS reduced the number of false positives relatively by 84.6% and 79.4% compared to TOKS and SOFA, respectively, at the same sensitivity of 0.4.

Discussion and conclusions: 

The AI-EWS outperformed the SOFA and TOKS in the early detection of sepsis, with an increase in AUROC by 29.4% and AUPRC by 241.7% when compared to TOKS, the currently used early warning tool in Denmark. We conclude that the AI–EWS could be used to improve clinical utility by enabling earlier sepsis interventions and should be tested in a prospective randomized trial.



Trial Registration: Not registered. Register study. Funding: This work was supported by the Innovation Fund Denmark (case number 8053-00076B). Ethical approval and informed consent: Not needed
Simon Meyer LAURITSEN (Aarhus, Denmark), Mads KRISTENSEN, Katrine Meyer LAURITSEN, Marianne Johansson JØRGENSEN, Jeppe LANGE, Bo THIESSON
11:30 - 11:40 #18411 - OP075 Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: a prospective interventional study.
OP075 Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: a prospective interventional study.

Background
It has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.

Methods
In this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥2).


Results
A total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%-21.7%) and 98.8% (95% CI, 97.0%-99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [-0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference -2.9%, 95% CI [-13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%-128.3%), with a median number of 157 ED visits per day (IQR, 147- 169).

Conclusions
A qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.



Trial registration (ClinicalTrials.gov) NCT03299894
Julien PETIT (Orléans), Julien PASSERIEUX, Thierry BOULAIN, François BARBIER
11:40 - 11:50 #18500 - OP076 High-dose of beta-lactam therapy and associated outcomes in sepsis and septic shock patients in a university emergency department, Thailand.
OP076 High-dose of beta-lactam therapy and associated outcomes in sepsis and septic shock patients in a university emergency department, Thailand.

Introduction

Altered pharmacokinetics, including increased volume of distribution and reduced tissue perfusion, in sepsis and septic shock patients resulted in inadequate serum drug concentration with the given standard meropenem dose. Even though higher dose regimen of hydrophilic antimicrobials was proposed, high-dose meropenem and its associated clinical outcomes in sepsis and septic shock patients admitted in the emergency department (ED), Mahidol university hospital, Thailand has not been examined.

Study objective

To compare the clinical outcomes of high-dose meropenem versus standard-dose in sepsis and septic shock patients who were admitted to the ED, Ramathibodi Hospital, Bangkok, Thailand.

Method

All sepsis and septic shock patients, in whom treatment with meropenem was indicated, were included in the study. Patients were randomized into two groups: the high-dose group (meropenem 2 g, infusion 3 hours, every 8 hours) and the standard-dose group (meropenem 1 g, infusion 3 hours, every 8 hours). Dose adjustment was done according to the renal dose adjustment protocol. Data were collected on 35 patients over 1 year. Primary and secondary outcomes included changes of modified sepsis-related organ failure assessment (mSOFA), mortality rate, ICU length of stay, mechanical ventilator days, vasopressor days and hospital stay.

Results

The study included 35 patients with 17 patients receiving standard-dose and 18 patients receiving high-dose meropenem. Age, gender, body weight, comorbidities, severity of illness, and source of infection were comparable between groups. Among identified pathogens, more than 80% were gram negative pathogens and all of them had meropenem minimal inhibitory concentration (MIC) < 0.5 mg/dL. Delta mSOFA scores were not different between two groups (-2 [range -6 to 2] in standard-dose group vs -2 [range -9 to 4] in high-dose group, P-Value = 0.99). There was no difference between standard-dose group and high-dose group in ICU mortality (17.6% vs 11.1%, P-value = 0.66), ICU free days (16.6±10.6 vs 14.5±11.8, P-value = 0.59), mechanical ventilator free days (18 [range0-28] vs 20.5 [range 0-28], P-value = 0.57), vasopressor free days (9.7±5.7 vs 8.9±5.8, P-value = 0.68) and hospital free days (50.8±33.5 vs 47.1±36.0, P-value = 0.75).

Conclusion

Our study is the first study examining higher dosing of meropenem in the ED, Ramathibodi Hospital, Bangkok, Thailand. The high-dose group showed comparable clinical outcomes to the standard dose group. Even though higher dose of hydrophilic antimicrobials has been linked to the better clinical outcomes in sepsis and septic shock patients, high-dose meropenem in low MIC pathogen has not been associated with improved clinical outcomes. Further research might be needed in order to identify suitable septic shock patients who may benefit from receiving high-dose of meropenem.

References

1.Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377.

2.Roberts JA, Paul SK, Akova M, et al. DALI: defining antibiotic levels in intensive care unit patients: are current beta-lactam antibiotic doses sufficient for critically ill patients?. Clin Infect Dis. 2014 Apr;58(8):1072-83. 



This study was registered using ClinicalTrial.gov identifier NCT03374722 and we have got funding from Dr.Kasem Foundation, Thailand.
Pitchaya DILOKPATTANAMONGKOL (Bangkok, Thailand), Auranee TRISATAYA, Viratch TANGSUJARITVIJIT, Jetjamnong SUEAJAI, Preecha MONTAKARNTIKUL, Tospon LERTWATTANACHAI
11:50 - 12:00 #18799 - OP077 Albumin outperforms other novel biomarkers in prognosticating sepsis-associated mortality for sepsis patients in emergency department.
OP077 Albumin outperforms other novel biomarkers in prognosticating sepsis-associated mortality for sepsis patients in emergency department.

Background

Sepsis can be fatal without timely diagnosis and prompt intervention. Therefore, it is necessary to develop early predictive biomarkers to identify and risk-stratify patients with sepsis. Traditionally, albumin has been used as a nutritional biomarker in intensive care unit to predict the mortality of septic patients; however, its role in prognosticating patients with sepsis in the emergency department (ED) remains uncertain.

 

Objective

The aim of the current study is to evaluate the performance between conventional and novel biomarkers in predicting 28-days sepsis-associated mortality and bacteremia in the ED. 

 

Methods

This prospective hospital-based cohort study was conducted in the ED of two different tertiary medical centers in Northern Taiwan between 2012 and 2018. Patients with documented infectious diseases during initial 24 hours were enrolled. We applied the multiplex platform of Bio-Plex ProTM Assays to evaluate 14 novel biomarkers: angipoietin-2, pentraxin 3, triggering receptor expressed on myeloid cells 1 (TREM-1), intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion protein 1 (VCAM-1), soluble cluster of differentiation 14 and 163 (sCD14 and sCD163), E-selectin,  P-selectin, tumor necrosis factor alpha (TNF alpha), cluster of differentiation-64 (CD64), interleukin-6, interleukin-8 and interleukin-10. Besides, we assessed 7 conventional markers: albumin, procalcitonin (PCT), C-reactive protein (CRP), red cell distribution width (RDW), Sequential Organ Failure Assessment (SOFA) score, Systemic Inflammatory Response Syndrome (SIRS) and Chills, Hypothermia, Anemia, RDW and Malignancy (CHARM) score. Our main outcomes of biomarker performance included sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC). 

 

Results

We recruited 1478 patients in our study. Among them, 1155 subjects had SIRS (78.15%), 912 subjects had severe sepsis (or Sepsis 3.0, 61.71%), and 466 subjects had septic shock  (31.53%)  with a 28-day mortality rate of 8.15%. By using different cutoff values of albumin, we demonstrated relatively acceptable sensitivity, specificity and accuracy for sepsis-associated mortality prediction accordingly (albumin level of 2.5g/dL: 34.51%, 93.90%, 88.20%; albumin level of 3.5g/dL: 90.27%, 44.41%, 48.81%). Among all biomarkers, albumin alone possessed an AUC of 0.791 (95% CI 0.750-0.832) and its performance was similar to the SOFA score with an AUC of 0.792 (95% CI 0.750-0.833) in 28-days sepsis-associated mortality (p-value = 0.98). For bacteremia, procalcitonin had a higher AUC than CRP (0.799, 95% CI 0.744-0.854 versus 0.540, 95% CI 0.467-0.611; p-value < 0.0001), as well as other biomarkers and scoring systems.

 

Conclusion

Our finding suggests that albumin, as a single biomarker, is a promising early predictor for mortality in sepsis subjects, similar to SOFA score, and outweighs other markers. The role of biomarker in identifying bacteremia has proved that PCT is still a better tool in comparison with CRP. Further efforts are needed to evaluate and improve the reliability of combining two or more biomarkers in early prediction of sepsis-associated mortality.



The study was supported by the Ministry of Science and Technology (Taiwan) and Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Dr Su Ann YONG (Taipei, Taiwan, China), Chia-Yu CHAO, Kuan-Fu CHEN
12:00 - 12:10 #18953 - OP078 Characteristics of low energy expenditure in the acute phase of sepsis.
OP078 Characteristics of low energy expenditure in the acute phase of sepsis.

Background: With regards to nutritional therapy in critical care, the guidelines recommend that hypocaloric nutrition (not exceeding 70% of the estimated needs) be administered in the early phase of acute critical illness. When indirect calorimetry (IC) was used to study resting energy expenditure (REE) in the acute phase of sepsis (within 72 hours of admission), it was found that patients showed lower energy expenditure than that calculated using simple weight-based equations (such as 20-25 kcal/kg/day). This study aimed to evaluate the characteristics of low energy expenditure in the acute phase of sepsis.

Method: This retrospective observational study included sepsis patients under ventilation in whom REE was measured using IC within the first 72 hours of admission. The patients were divided into two groups according to REE values: group A, REE <20 kcal/kg/day and group B, REE ≥20 kcal/kg/day. Age, sex, body mass index (BMI), comorbidities, Acute Physiology and Chronic Health Enquiry (APACHE II) score on admission, site of infection, causative microorganisms, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy were compared between the two groups. The Wilcoxon rank-sum test and the Fisher’s exact test were used for statistical analysis. A p-value <0.05 was considered statistically significant. We conducted this study in accordance with the Declaration of Helsinki, and the study was approved by the institutional review board at Osaka University Hospital (approval no. 14186). The board waived the need for informed consent because this was a retrospective study using clinical data.

Results: This study included 28 patients. Group A included 39.3% (n=11) of the study population. Median (interquartile range) age was significantly higher in group A than in group B (81 [74-87] vs. 72 [62-76] years; p=0.02). APACHE II scores were significantly higher in group A than in group B (24 [22-34] vs. 19 [14-25], p=0.04). Median BMI was significantly lower in group A than in group B (19.6 [17.6-24.9] vs. 23.6 [21.4-27.7] kg/m2; p=0.05). Microorganism culture showed gram-negative rods in the following cases: seven cases in group A (63.6%) and three cases in group B (17.7%) (p=0.02). Sex, comorbidities, site of infection, ratio of positive blood culture, catecholamine administration, and corticosteroid therapy did not differ significantly between the two groups.

Conclusion: Low energy expenditure in the acute phase of sepsis was observed in patients with higher APACHE II scores and lower BMI. The type of causative microorganism could also be related to for metabolism.


Dr Takeshi EBIHARA (OSAKA, Japan), Kentaro SHIMIZU, Hiroshi OGURA, Takeshi SHIMAZU
12:10 - 12:20 #19016 - OP079 Bacteraemia in patients with accidental hypothermia: a retrospective cohort study.
OP079 Bacteraemia in patients with accidental hypothermia: a retrospective cohort study.

Background

Accidental hypothermia is not only caused by environmental exposure but also by various medical conditions, including sepsis, endocrinologic disease, and multiple trauma. Bacteraemia in accidental hypothermia is considered to be associated with significant morbidity and mortality, but little is known about bacteraemia in patients with accidental hypothermia. We aimed to investigate the clinical characteristics of patients with both accidental hypothermia and bacteraemia.

Methods

We conducted a retrospective analysis of all adult patients with accidental hypothermia who were brought to an urban emergency department between July 2011 and March 2019 in Kobe, Japan. Hypothermia was defined as a body temperature below 35°C.We compared clinical characteristics (vital signs, comorbidities, and laboratory tests) between patients with and without bacteraemia. To assess whether bacteraemia was associated with in-hospital mortality, we analysed odds ratios using a logistic regression model. Based on biological plausibility and pre-existing knowledge, we selected the following confounding factors: age, sex, severity (the Swiss system), and Charlson comorbidity index.

Result

A total of 245 patients with accidental hypothermia were enrolled. Median age was 78 (interquartile range, 68 to 87) years, and 49% of patients were male. In the emergency department, blood culture samples were collected from 217 patients (89%); of these, 36 patients (16.6%) showed positive blood cultures. None of the patients for whom blood culture was not performed in the emergency department were diagnosed with bacteraemia after admission. Body temperatures were lower (28.9 vs 30.1°C, p=0.009) and C-reactive protein levels were higher (9.99 vs 3.76 mg/dL, p<0.001) in patients with bacteraemia than in those without bacteraemia. Other clinical characteristics were not different between the two groups. The mortality was 11/36 (31%) in patients with bacteraemia and 29/209 (14%) in patients without bacteraemia (adjusted odds ratio, 2.47 [95% confidence interval, 1.04–5.88]).

Discussion and conclusion

Our study demonstrated that bacteraemia was common in patients with accidental hypothermia and was a prognostic factor, even after adjusting for confounding factors. Furthermore, except for body temperature and one inflammatory marker, other clinical characteristics did not differ between patients with and without bacteraemia. High mortality has been reported in accidental hypothermia patients with bacteraemia, but limited information was available for correctly suspecting bacteraemia in the emergency department. Our results were clinically acceptable and also consistent with a multi-centre study that demonstrated that hypothermia was associated with higher mortality in sepsis patients. Although several previous studies have focused on the association between mortality and hypothermia from the standpoint of treating sepsis patients, we evaluated all patients who presented with accidental hypothermia. Therefore, the present study emphasizes the importance of suspecting bacteraemia in patients with accidental hypothermia who do not show signs of sepsis. In conclusion, our study found that bacteraemia was common in patients with accidental hypothermia and was associated with higher mortality. Based on these findings, we recommend that we take blood culture routinely and consider empirical antibiotic treatment in patients with accidental hypothermia.



none
Dr Mayu KURIBAYASHI (kobe, Japan), Yoshinori MATSUOKA, Koichi ARIYOSHI
12:20 - 12:30 #19116 - OP080 Recognition of sepsis through emergency medical services.
OP080 Recognition of sepsis through emergency medical services.

Recognition of sepsis through emergency medical service

Background:

Sepsis is a common and serious disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sepsis-related Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Accordingly emergency medical services (EMS) in Bavaria were trained to identify septic patients in the prehospital setting. This retrospective cohort study sought to evaluate the effectiveness of this training intervention.

Methods:

We performed a retrospective study of all patients transported by EMS to our ED during two 6-month periods. All patients with a suspected or proven infection and sepsis after the ED workup were included. 303 patients were included during the 6 month period before the EMS training for sepsis recognition and 459 patients were included in the 6 month period following the EMS training. The sensitivity and specificity of a qSOFA score ≥2 for ED identification of patients at risk of complication was calculated.

Results:

During the 12 month study period 3.1% of all EMS-transported patients were diagnosed with sepsis in the ED. Mean age of the study cohort was 72 ±13 years, 59.4% were male, 60% needed intensive care, hospital mortality was 37.7%. No significant differences in clinical and outcome variables between the two study periods were noted. The proportion of patients identified with sepsis by EMS did not increase in the study period following the EMS training. In both study periods the identification of a septic disease in the pre-hospital setting was missed in 82% of the patients. Only in 3.8% a qSOFA score ≥2 was documented. Respiratory rate was the vital parameter most often missed by EMS (60%). In the ED the sensitivity and specificity of a qSOFA score ≥2 for identification of septic patients with poor outcome was 37.2% and 84.2%, respectively.

Conclusions:

A single EMS training period for identification of septic patients in the prehospital setting is not sufficient. A qSOFA score ≥2 had a low identification sensitivity in selecting septic patients at risk of complication upon arrival in the ED. An improved method for pre-hospital identification of septic patients is needed.



Funding: University of Augsburg research fund
Markus WEHLER, Thomas HÄNDL (Augsburg, Germany), Jürgen NEUBAUER
12:30 - 12:40 #19200 - OP081 Sepsis after Sepsis-3: A prospective study of the incidence and the prognostic accuracy of the diagnostic tools for early detection of sepsis.
OP081 Sepsis after Sepsis-3: A prospective study of the incidence and the prognostic accuracy of the diagnostic tools for early detection of sepsis.

Background

Prospective studies of the incidence of sepsis and the prognostic accuracy of the different sepsis screening tools after the introduction of Sepsis-3 are limited. Definition of sepsis is now based on organ dysfunction characterized by a rise in the Sequential Organ Failure Assessment (SOFA) score of two or more. The new definition also proposed QuickSOFA (qSOFA) as a bedside screening tool to identify patient with potential risk of having sepsis. We have estimated the incidence based on qSOFA, SOFA and Systemic Inflammatory Response Syndrome (SIRS), and compared the prognostic accuracy in predicting the 28-day mortality.

 

Methods

A prospective observational cohort study of infected patients aged 18 years or older admitted to the emergency department (ED) of Slagelse Hospital during 01.10.2017 – 31.03.2018. The adult (≥18 years) population in the area was 198,000. All patients with suspected or documented infection on arrival to the ED, and treated with antibiotics, were included. Admission variables included in the qSOFA, SOFA and SIRS criteria were obtained from the triage forms and patient records. The applied SOFA values were calculated based on the clinical and paraclinical parameters at admission and with correction for chronic dysfunction of organs included in the SOFA score. Survival status was obtained from the Danish Civil Registration System. Incidence was estimated as (number of patients with sepsis/population in the area x 0.5) x 100.000.  The prognostic accuracy was assessed by analyses of sensitivity, specificity and area under the receiver-operating curve (AUROC) with 95% confidence intervals (CI).

Results

A total of 2,112 patients with median age of 73.1 years were included. The incidence of sepsis based on a qSOFA 2, a SOFA 2 and SIRS 2 was 175/100,000 (95% CI 150-203/100,000), 714/100,000 (95% CI 663-768/100,000) and 1,012/100,000 (95% CI 951-1076/100,000), respectively. The 28-day mortality in patients with qSOFA 2, SOFA 2 and SIRS 2 was 17.7% (95% CI 12.4-24.2), 13.6% (95% CI 11.2-16.3) and 8.3% (95% CI 6.7-10.2), respectively. qSOFA 2 had a sensitivity of 19.5% (95% CI 13.6-26.5) and a specificity of 92.6% (95% CI 91.4-93.7), SOFA 2 had a sensitivity of 61.0% (95% CI 53.0-68.6) and specificity of 68.4 (95% CI 66.3-70.59), and SIRS 2 had a sensitivity of 52.8% (95% CI 44.8-60.8) and a specificity of 52.5% (95% CI 50.2-54.7). The AUROC was 0.63 (95% CI 0.59-0.67) for qSOFA, 0.69 (95% CI 0.64-0.73) for SOFA and 0.52 (95% CI 0.48-0.57) for SIRS.

 

Discussion and conclusion

The sepsis-3 criteria have reduced the number of patients classified as having sepsis and the prognostic accuracy to predict 28-day mortality has been increased. However, the prognostic accuracy to predict patients with risk of death is still poor, regardless of the scoring system used. 



The study received financial support from Region Zealand Health Research Foundation (RSSF), Denmark and “Naestved, Slagelse and Ringsted Hospitals” Research Fund, Denmark.
Dr S M Osama Bin ABDULLAH (Copenhagen, Denmark), Rune Husås SØRENSEN, Ram Benny Christian DESSAU, Saifullah Muhammed Rafid Us SATTAR, Lothar WIESE, Finn Erland NIELSEN
TERRACE 2B
12:40 LUNCH BREAK AND EXHIBITION

Tuesday 15 October

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A32bis
12:40 - 14:10

EUSEM Annual General Assembly
for members only

CONGRESS HALL
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A33
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Psychology in the Emergency Department
All in the Mind: The Psychology of an Emergency Physician
Psychology

Moderators: Simon CARLEY (Consultant in Emergency Medicine) (Manchester), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
14:10 - 15:40 Frust and Anger among Patients and Relatives - Understand their Perception of Reality. Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, Germany)
14:10 - 15:40 How to handle fear of failure and mutate from a fraidy-cat to a risk-taker. Simon CARLEY (Consultant in Emergency Medicine) (Manchester)
14:10 - 15:40 Dr. Greg´s Travalin Medical Magic Show. Greg HENRY (USA)
14:10 - 15:40 Mistakes are for Learnin'. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
CONGRESS HALL

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Bohemian Sono Rhapsody
Sonography, Ultrasound

Moderators: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne), Dr Nicolas LIM (Intensive Care Fellow) (Dublin, Ireland), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland), Eftychia POLYZOGOPOULOU (ASSISTANT PROFESSOR OF EMERGENCY MEDICINE) (ATHENS, Greece)
14:10 - 15:40 Interactive ultrasound game show. Nils Petter OVELAND (Doctor) (Stavanger, Norway), Tomas VILLEN (Attending Physician) (Madrid, Spain), Rip GANGAHAR (Consultant) (OLDHAM), Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA), Dr Michael SWEENEY (Consultant) (Sligo, Ireland), Mohit ARORA (Consultant Emergency Medicine) (LEEDS), Laila ALAWI HUSSEIN (Specialist Emergency Medicine) (AbuDhabi, United Arab Emirates)
FORUM HALL

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C33
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Geriatric emergencies
Hot topics in the care of the elderly
Geriatric, HOT TOPIC SPEAKER!

Moderators: Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, United Kingdom), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
14:10 - 14:25 What you need to know about old people - and how to learn it. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, Canada)
14:25 - 14:40 Risk stratification of older patients. Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
14:40 - 14:55 Short stay unit. Dr Camilla STRØM (MD. PhD Research Fellow) (Copenhagen, Denmark)
14:55 - 15:10 Prehospital geriatric emergency medicine. Eric REVUE (Chef de Service) (Paris, France)
15:10 - 15:40 Panel Discussion. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, Canada), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland), Eric REVUE (Chef de Service) (Paris, France), Dr Camilla STRØM (MD. PhD Research Fellow) (Copenhagen, Denmark)
SOUTH HALL 3AB

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YEMD - Very difficult situations, once in a lifetime?
The situations we don't see everyday - but need be prepared for!
Hematology, Resuscitation, Young Emergency Medecine

Moderators: Bulut DEMIREL (Clinical Development Fellow) (Glasgow), Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, Croatia)
14:10 - 15:40 Surviving hematological emergencies. Eva DIEHL-WIESENECKER (Physician) (Berlin, Germany)
14:10 - 15:40 Jack in the box - uncommon presentations. Farah MUSTAFA (EMERGENCY MEDICINE CONSULTANT) (Drogheda, Ireland)
14:10 - 15:40 To treat or not to treat. Or: Mr. Bayes - Take over! Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, Belgium)
14:10 - 15:40 Worst case: Resuscitating one of your own team - what now? Riccardo LETO (Chief of ED) (Overpelt, Belgium)
SOUTH HALL 3C

Tuesday 15 October

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NURSES
Implementing evidence based care
Nurses

Moderators: Emmanuel ROHRBACHER (INFIRMIER) (MONCONTOUR DE BRETAGNE, France), Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, The Netherlands)
14:10 - 15:40 Introduction to implementation science. Jochen BERGS (Hasselt, Belgium)
14:10 - 15:40 Protocol adherence in emergency care. Dr Remco EBBEN (Associate professor/lecturer) (Nijmegen, The Netherlands)
14:10 - 15:40 Implementing nursing handover: a hospitals journey. Christian GILOT (Head Nurse) (Rumst, Belgium), Jochen BERGS (Hasselt, Belgium)
CHAMBER HALL

Tuesday 15 October

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F33
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ABSTRACTS SESSION

Moderators: Door LAUWAERT (Manager) (BRUSSELS, Belgium), Marc SABBE (Medical staff member) (Leuven, Belgium)
14:10 - 14:20 #18016 - OP082 Needs Assessment for Standardized Educational Program for Iranian Medical Students in Crisis and Disaster Management.
OP082 Needs Assessment for Standardized Educational Program for Iranian Medical Students in Crisis and Disaster Management.

Background: Early education and training are mandatory to raise the knowledge and awareness of the healthcare staff. Iran is a disaster prone area with a high number of emergencies. This study aimed to assess the need for disaster and emergency management education for Iranian medical students.

Methods: Using two-round Delphi technique in 2018, 15 experts within the field of disaster and emergency management were asked for their opinions concerning the education required for Iranian medical students. Highly important educational domains and their sub-domains selected with an agreement of above 70-80% were prioritized by AHP technique.

Results: Of 41 identified and prioritized educational subjects, four main groups were obtained: 1) crisis and disaster primary concepts, 2) disease control skills, 3) management skills, and 4) medical care skills. The medical care skills had the highest priority (with a weight of 0.546) compared to other areas after the final analysis.

Discussion and Conclusion: Different areas of competency are needed to raise awareness and preparedness in medical students in combating crisis and disasters. We propose a curriculum for Iranian medical students and suggest it to be used other professionals, who are involved in the process of disaster management.



Registration: Nil. Funding: This project has partly been supported by a grant from the Shiraz University of Medical Sciences. Ethical approval and informed consent: Informed consent was obtained from all individual participants included in the study.
Rezaee RITA, Peyravi MAHMOUDREZA (Shiraz, Islamic Republic of Iran), Ahmadi Marzaleh MILAD, Khorram-Manesh AMIR
14:20 - 14:30 #18663 - OP083 ED impact of a mass gathering pre-hospital support system: the Rouen 2013 Armada event.
OP083 ED impact of a mass gathering pre-hospital support system: the Rouen 2013 Armada event.

ABSTRACT

Objective(s)

There is no data about the intra-hospital crowding effect of pre-hospital mass-gathering support systems. Our objective was to evaluate the impact on emergency departments (EDs) of the Rouen Armada event 2013 (RAE2013), a major French happening.

Methods

We performed a multicenter, observational study based on the prospective collection of data on-site (8 first aid stations) and from 5 EDs in the Rouen area.

The main study endpoint was the total number of patients presenting to EDs for an Armada-related reason (ARR). Secondary endpoints were: demographics, care pathways, final diagnosis, care characteristics and outcomes. Then, we performed a focussed analysis on two subgroups (with vs without pre-hospital examination).

Results

Among 1,261 patients examined on-site, 246 presented to ED with an ARR (63 % with accidental injury, 85% discharged home). Only 6 patients had severe injuries. 88% of patients required some technical support in the ED. In the subgroup without pre-hospital examination (49%), we found significantly higher rates of young and local patients, which mainly presented to a private hospital. In the other subgroup, we fund a higher significant rate of discomfort and more use of ED technical support (biology, EKG).

Conclusions

RAE2013 pre-hospital support system efficiently protected EDs from overcrowding. Most of the ED visits were appropriate. This study highlights the importance of sufficient on-site resources for the most common presentations, and the relevance of intra-hospital registers.


Julie DUMOUCHEL (Tours), Dr Melanie ROUSSEL, Mehdi TAALBA, Virginie Eve LVOVSCHI, Antoine LEFEVRE, Luc Marie JOLY
14:30 - 14:40 #18256 - OP084 Public Knowledge in basic life support maneuvers and attitude towards emergencies in Spain.
OP084 Public Knowledge in basic life support maneuvers and attitude towards emergencies in Spain.

Introduction: out-of-hospital cardiac arrest (OHCA) is a major public health problem. In Spain there are about 15,000 cases per year. The survival with a good neurological status of the OHCA is low, around 10%. Several studies have shown the relationship between the levels of training of citizens, the number of witnesses performing cardiopulmonary resuscitation (CPR) and the survival to the OHCA. The objective of this study was to determine the level of knowledge in basic life support (BLS) maneuvers of the Spanish population and their general attitude towards emergencies.

Methods: Descriptive study of cross-sectional survey by means of randomized sampling. 1,500 telephone interviews were made to subjects 18 years of age and older living in Spain. The sample was selected randomly from an automatic telephone number generator. The questionnaire used was designed specifically for the study. The information was collected by means of a computer-assisted telephone interview (CATI) through a structured and pre-codified questionnaire. Descriptive statistics was used to show the results.

Results: 51.3% of the people surveyed were men, the predominant age was between 35 and 54 years (44.9%), 59.7% were in active labor status and 32.8% had university studies. 75.6% of the population considers the training that Spanish people have in relation to first aid is "insufficient" or "very insufficient". 98.7% of respondents consider "very important" or "important" that citizens have knowledge of first aid. 60.8% of the population does not feel able to respond to a cardiac arrest. Only 41.3% of citizens recognize that they would know how to use an AED in case of need. 34.7% of Spanish people don´t know which is the unique European emergency number. 53.8% of the population has not received any training course related to first aid or BLS. 53.6% of citizens believe that caring for a person who has an emergency, without sufficient knowledge, could pose legal problems. 81.6% of the respondents believe that in our country everything is not done so that citizens have adequate training in first aid. 81.7% of the population believes that training in BLS should be initiated in the school (Primary Education and ESO).

Conclusions: Although the knowledge on BLS of the Spanish population and their ability to respond to an emergency situation has increased in the recent years, we are far from other European countries. The implementation of a National Plan of training and awareness in BLS along with public defibrillation programs, telephone CPR and public information and dissemination campaigns could increase the level of knowledge, the ability to respond, the number of witnesses that perform correctly CPR and use an AED, and, with all these things, can increase the survival of cardiac arrest.



The study was funded by the Mapfre Foundation
Esther GORJÓN (Madrid, Spain), Raúl SÁNCHEZ, Daniel BARQUILLA, César FERNÁNDEZ, Miguel GARVI
14:40 - 14:50 #18173 - OP085 Outcome prediction in emergency elderly admissions: derivation and external validation of the Geriatric Emergency Risk on Admission Score.
OP085 Outcome prediction in emergency elderly admissions: derivation and external validation of the Geriatric Emergency Risk on Admission Score.

Background

The over 65 demographic have demonstrated the largest increase in emergency hospital admissions of any age group. Measures of acute illness severity using only physiological parameters have shortcomings in the older patient. Accurate risk scores combining acute physiology e.g. National Early Warning Score (NEWS), co-morbidities, and Clinical Frailty Score (CFS) in this cohort may support clinical decision making and inform discussions with patients and carers. This study aimed to derive and externally validate an in-hospital mortality risk score for the acutely unwell older patient.

Methods

This multicentre cohort study collected data on non-elective admissions in those aged ≥65 years from the emergency departments of two UK district general hospitals (2017-2018), which were treated as independent populations to derive and validate the score. Accessible and clinically significant variables underwent regression analysis for in-hospital mortality. Independent predictors of mortality from the derivation cohort were used to create GERAS. Model performance was assessed for discrimination and calibration in the validation cohort. Area under curve (AUC) analysis is presented with 95% confidence intervals. Secondary outcomes measured were 48-hour and seven-day mortality, 30-day readmission, and extended hospital stay.

Results

17,905 admissions were analysed in both derivation (n= 8,974) and validation (n=8,931) cohorts. GERAS was stratified into low, medium, high, and severe risk with corresponding mortality in each group of 0.4, 3.9, 9.3, and 24.1 percent, respectively. GERAS AUC for in-hospital mortality was 0.79 (0.77-0.80), compared to NEWS at 0.65 (0.62-0.67) and CFS at 0.76 (0.74-0.77) alone. GERAS demonstrated better calibration than NEWS and Clinical Frailty Score, Hosmer-Lemeshow: 0.302 vs 0.157 and 0.008, respectively. AUCs for mortality prediction at 48-hours and 7-days were 0.84 (0.78-0.90) and 0.83 (0.79-0.86), respectively. AUCs for 30-day re-admission and extended hospital stay were 0.68 (0.65-0.70) and 0.52 (0.50-0.54), respectively.

Conclusion

GERAS is an easy to use, high discriminating risk score that could be integrated into existing electronic hospital systems for use within hours of admission. Future studies could validate GERAS in external populations and consider impact analysis.

 



Ethical approval: NHS South Central - Hampshire B Research Ethics Committee (REC reference 18/SC/0513)
Khushal ARJAN (Brighton, United Kingdom), Luke HODGSON
14:50 - 15:00 #18310 - OP086 Nonspecific Complaints in the Emergency Department – A Systematic Review.
OP086 Nonspecific Complaints in the Emergency Department – A Systematic Review.

ackground Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This systematic review aims to draw a synthesis of reported outcomes for patients presenting with NSC.

Methods We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the period of past 20 years. Included were studies with adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2057 studies were screened for eligibility and quality was assessed with the SIGN assessment for bias tool. We excluded any low-quality studies resulting in 9 studies for quantitative analysis. We analyzed included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and revisitation rate and compared outcomes to patients presenting with specific complaints (SC), where data was available. We grouped discharge diagnoses by ICD-10 categories.

Results We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 4.22 (95% CI 1.39-12.88)]. They were triaged as urgent less often than SC patients [OR 2.10 (95% CI 1.06- 4.15)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 4.93(95% CI 1.97-12.31)]. These patients seemed to require more resources than patients with SC. There was no significant increase in intensive care admissions. Data was insufficient to make conclusions regarding revisitation rates. Discharge diagnoses were spread throughout ICD-10 main chapters, infections being the most prevalent.

Conclusions Patients with NSC have a high risk of mortality, their care in the Emergency Department is slower and requires more resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.



The protocol has been registered with Prospero ID CRD42019123552 The authors report no confict of interest
Dr Kemp KIRSI (Helsinki, Finland), Reija MERTANEN, Leila NIEMI-MUROLA, Lasse LEHTONEN, Maaret CASTREN
15:00 - 15:10 #18402 - OP087 A review of reviews of Emergency Department interventions for older people: outcomes, costs and implementation factors.
OP087 A review of reviews of Emergency Department interventions for older people: outcomes, costs and implementation factors.

Background

 

Internationally, emergency and urgent care of older people is a public health priority. The management of older people in the Emergency and Urgent Care system remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively, effectively, and efficiently, understanding both their clinical and broader, holistic needs. It is important to consider the strategies and interventions that have been used in the emergency care of older people, and to evaluate the evidence as to their outcomes, costs, and implementation.

 

Methods

 

A number of reviews have previously taken place in this topic area, assessing diverse interventions with differing methods and variable outcomes. We developed and registered (PROSPERO, CRD42018111461) a protocol for a review of reviews. Database searches and complementary methods identified evidence from review articles and conference abstracts, which were screened according to pre-defined inclusion criteria relating to both subject and reporting standards. Data describing interventions for older people in Emergency Departments (ED) were extracted and summaries generated in tabular and narrative form. The quality and reporting of the reviews were assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to the heterogeneity of interventions and outcomes, findings were analysed narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a framework to classify ED interventions.

 

Results

 

Eighteen review articles and three conference abstracts met our topic and reporting standard inclusion criteria. The majority were described as systematic reviews, with four of these using meta-analysis. Fourteen of the reviews reported interventions that were either initiated or wholly delivered within the ED. The remaining four reviews reported non-interventional studies focussed predominantly on quality indicators or patient preferences.

 

Confidence in (US-dominated) research was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in the standards to which reviews were conducted and reported. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. In total, 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life.

 

Discussion

 

Our review of reviews demonstrated that the current, extensive evidence base of primary and review studies is lacking in complexity, with limited or no evidence for the effectiveness of ED interventions; a common feature of the reviews was a call for more primary research using rigorous evaluation methods. There is little evidence in review studies for factors that influence the implementation of interventions.

 

There was evidence that among interventions initiated in the ED, those which were continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as outcomes of interventions more frequently than person-centred attributes (as valued by older people). The interventions were broadly holistic in nature, consistent with international literature supporting Comprehensive Geriatric Assessment to improve outcomes for older people with acute care needs.



We undertook this review within a project which received NIHR Health Services and Delivery Research funding (17/05/96). JvO was supported by an NIHR Academic Clinical Fellowship.
James VAN OPPEN (Leicester, UK, ), Louise PRESTON, Suzanne ABLARD, Helen BUCKLEY WOODS, Suzanne MASON, Simon CONROY
15:10 - 15:20 #19352 - OP088 Initial findings and feasibility of in-situ qualitative interviews exploring older adults’ experiences of emergency department care.
OP088 Initial findings and feasibility of in-situ qualitative interviews exploring older adults’ experiences of emergency department care.

Background

Optimisation of care for older adults who present to emergency departments, is an area of increasing interest and a top-ranking priority in a recent research priority setting exercise, led by the UK Royal College of Emergency Medicine and the James Lind Alliance.  

Questionnaires that enable patients to report the quality of their healthcare experience are known as Patient Reported Experience Measures (PREMs).  Each year millions of patients attend Emergency Departments (EDs), however no sufficiently reliable or validated PREM has yet been developed for use in this context. The Patient Reported Experience Measure for Adults aged over 65 years (PREM-ED 65+), is intended to be a validated and reliable PREM for use amongst older adults attending the ED. However, in order to generate items for the PREM, determinants of experience for older adults attending the ED need to be captured.

This study aims to describe the experiences of adults, aged 65 years or over, who attend the ED, focusing specifically on the feasibility and challenges of administering qualitative interviews in this clinical context (ED).

Methods

The study was conducted in a single large UK ED (100,000 attendances/year). English speaking patients aged 65 years or older, who consented to participate, were recruited between December 2018 and April 2019.  Sampling was purposive based on age, gender, presentation type and frailty score. Semi- structured interviews were conducted within the ED before discharge or inpatient disposition. Interviews were audio recorded and a standard question guide used. Ethics approval was obtained from the UK NHS Health Research Authority (18/LO/1194).

A ‘needs based’ conceptual model for patient experience, developed from a prior meta-synthesis of qualitative literature, informed our analysis, building on the descriptive themes which are ‘communication needs’, ‘emotional needs’, ‘physical/ environmental needs’, and ‘care needs’. Our intention is to triangulate new or emerging themes with the views of staff members, to inform PREM-ED 65+.

Results:

In total, 24 patient interviews were conducted. The average age of participants was 75 years (range 65—89years), 15/25 (60%) were female, and all lived in their own home prior to attending the ED.  The average clinical frailty scale score was 3/9 (Range 1—6).  A total of 10 hours of data was obtained during interviews which averaged 25mins in length (range 9min—51min).

Discussion & Conclusions

Initial findings from the thematic analysis will be presented. This will include key themes related to older adults’ experiences of ED care and suggested items for inclusion within a new PREM, aimed at older adults attending the ED. 

We conclude that ‘in-situ’ qualitative interviews are feasible within the Emergency Department, potentially being less affected by recall bias than retrospective interviewing. However, conducting qualitative research within emergency departments which are crowded, with high levels of ambient noise and with frequent interruptions, are key limitations to the recruitment of frail older adults into qualitative research.



The first author is in receipt of a personal doctoral research fellowship, awarded by the UK Royal College of Emergency Medicine. This study did not receive any additional funding.
Blair GRAHAM (Plymouth, United Kingdom), Jason E SMITH, Ruth ENDACOTT, Rosalyn SQUIRE, Pamela NELMES, Jos M LATOUR
15:20 - 15:30 #18161 - OP089 Prevalence and severity of traumatic intracranial hemorrhage in older patients with low-energy falls – a retrospective study.
OP089 Prevalence and severity of traumatic intracranial hemorrhage in older patients with low-energy falls – a retrospective study.

Background

Low-energy falls (LEF) in the older patient are a common reason for presentation to an emergency department (ED). Head injuries, including traumatic intracranial hemorrhage (tICH) are among the common fall related injuries in this population. Current clinical decision rules consider anticoagulation (AC) or antiplatelet (AP) therapy as potential risk factor for a tICH. The objective of the study was to analyze the prevalence and severity of tICH and the association to AC/AP therapy in a large cohort of older patients with LEF presenting without trauma-team activation.

Methods

We performed a bicentric retrospective study on patients of 65 years and older presenting to the ED with a LEF between 01 January 2016 and 31 December 2016. Patients presenting to one of the two tertiary care centers (Emergency Departments of the University Hospital Basel and the University Hospital Munich) who obtained cranial computed tomography (cCT) examinations were included. Primary data were retrieved from radiology databases, detailed chart review abstractions were conducted by two independent observers to obtain information about medication, clinical signs of head injury and final diagnosis in both study centers. The prevalence and severity of tICH of patients with and without AC/AP therapy were compared. Multivariate regression models were used to measure the association between AC/AP therapy and the risk for tICH after adjustment for known predictors.

Results

Overall 2567 patients met inclusion criteria, of these 1424 (55%) had an AC/AP therapy. Prevalence for a tICH detected by cCT was 176/2567 (6.9%). Multivariate regression models showed no differences for the risk of a tICH (OR: 1.05, 95% CI: 0.76–1.47, p = 0.76) or association with head specific injury severity (IRR: 1.08, 95% CI: 0.97–1.19, p = 0.15) in patients with or without AC/AP therapy. CT-detected skull fracture and injury signs above clavicle were the strongest predictors for tICH (OR: 4.28, 95% CI: 2.79- 6.51 respectively OR: 1.88, 95% CI: 1.3–2.73).

Discussion and Conclusion

In this retrospective bicentric cohort analysis we found an overall prevalence of 6.9% for tICH in older patients with LEF and ED presentation without trauma-team activation. Therapy with AP/AC agents resulted in a prevalence of 7.2%, compared to 6.8% in patients without AP/AC therapy. Multivariate analysis revealed that neither AC, nor AP therapy or the combined treatment with AC and AP were risk factors for tICH in older patients with LEF. Injury signs above the clavicle were the strongest clinical predictor for a tICH and should therefore be considered to trigger imaging of the head in older patients with LEF, independently of AC or AP medication history.

The study was planned using STROBE guidelines, in accordance with the declaration of Helsinki, approved by local ethic committees (EKNZ 2017-01078, EK LMU 17-217).


Alina LAMPART, Tobias KUSTER, Isabelle ARNOLD, Nina MAEDER, Sandra NIEDERMEIER, Christian NICKEL, Roland BINGISSER, Dr Vera PEDERSEN (Munich, Germany)
15:30 - 15:40 #18976 - OP090 A Retrospective Chart Analysis of Early Postpartum Complications Resulting in Visits to the Emergency Department.
OP090 A Retrospective Chart Analysis of Early Postpartum Complications Resulting in Visits to the Emergency Department.

Background: With increasing fiscal restraints and the need for efficient delivery models, women are being discharged sooner postpartum. As a consequence, complications that would easily be dealt with are now being captured later. These patients present to the Emergency Department (ED) to access quicker care to manage these complications. The purpose of this study was to review the reasons that postpartum women present to the ED in the short term (≤10 days post delivery).

Methods: This was a retrospective study based out of a large community hospital, which has the highest birth rate in the province of Ontario, Canada. Research ethics approval was obtained. Women who delivered at William Osler Health Services (WOHS) between January 1, 2018 and December 31, 2018 and who presented to the ED within 10 days of delivery. Patient demographics, obstetrical parameters, type of delivery, time of ED visit, and management were all extracted. The primary outcome is the rate of and reasons for postpartum visits to the emergency department. The secondary outcome is to identify maternal characteristics that are associated with postpartum visits to the emergency department. Descriptive statistics were used to summarize the findings.

Results/Findings: In 2018, there were approximately 8000 deliveries across WOHS. There were 429 unique postpartum ED visits between January 1 and December 31, 2018, of which 382 were included in the analysis. The mean age was 31.21 years (range 19.00 to 43.00, SD 4.83). The mean gravidity was 2.28, and the median gestational age at delivery was 39.14 weeks (range 20.00 to 41.43, SD 2.29). Most of the patients delivered via spontaneous vaginal delivery (52.36%), and the rate of operative vaginal delivery and caesarean section was 7.85% and 39.79% respectively. Group B Streptococcus status was positive in 17.80% of all patients. The median time of presentation to the ED was 5.00 days (IQR 4.00 to 8.00, SD 2.51). The most common reasons for presentation were abdominal pain (17.02%), wound issue (13.09%), and fever or vaginal/rectal pain (9.95%). Only a quarter of cases required an obstetrical consultation, and 85.86% of all visits were discharged home. The rate of admission and transfer to another centre is 12.04% and 2.09% respectively.

Conclusion: This study was the first in a busy community setting that looked at return ED visits in the short-term postpartum period. Educating patients on pain management and wound care can potentially decrease the rate of ED visits by this patient population given the high incidence of patients presenting with this problem. Further studies are needed to review the role of patient education, home care, and the need for early obstetrical follow up to reduce ED visits.


Dr Prabhpreet HUNDAL (Brampton, Canada), Cassandra QUAN, Shayan ASSAIE, Leila SALEHI, Prashant PHALPHER, Maher ABOU-SEIDO, Rahim VALANI
TERRACE 2B
15:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
15:45

Tuesday 15 October

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EPOSTER 5.1
15:45 - 16:05

ePoster 5.1 - Short Oral Presentation - Screen 1

Moderator: Pr Riccardo PINI (Director, E.D. High Dependency Unit) (Florence, Italy)
15:45 - 15:50 #17922 - SP081 What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?
SP081 What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?

Background

The year 2013 saw the publication of minimum standards for medical teams working internationally in response to disasters.  This has been a true game-changer and pivot point for emergency medical team (EMT) practice worldwide and has set in motion a process of world health organisation (WHO) verification which seeks to ensure that EMTs are working to a minimum acceptable standard and when called upon to assist a foreign government with a disaster, they are actually able to perform as expected.  Within this process it was recognised that in order for EMTs to develop to this standard, certain guidelines for best practice would be needed.  One area which warranted its own working group was the minimum data set (MDS) for daily reporting.  In 2017 the WHO produced its first MDS for EMT daily reporting during sudden onset disasters (SODs), following expert consensus.  The initial challenge lies in ensuring EMTs adopt this MDS under the direction of in-country ministries of health (MoHs). However the subsequent challenge is understanding the utility of the data to help resource-manage an acute response.  This study looks at the specific coding of injuries to determine how reproducible the coding of severity is between practitioners using the WHO EMT MDS.

Methods

25 clinical case vignettes were developed to reflect potential injuries encountered in a SOD. These were presented in an online format between April and July 2018 to practitioners who have experience of/training in managing patients in SODs.  The pool of participants was derived from three sources: UK-Med’s register members, the Australian Medical Assistance Team (AUSMAT)’s Northern Territory members and the New Zealand Medical Assistance Team (NZMAT) clinical members.  UK-Med hosts and trains National Health Service (NHS) medical staff for the UK Emergency Medical Team (UK EMT) and both AUSMAT and NZMAT have a register of practitioners engaged in and interested in disaster response.  The participant pool was restricted to those who encounter injured patients in their clinical practice.  Practitioners were asked to code each injury according to the WHO EMT MDS case classifications.  Randolph’s kappa statistic for free-marginal multi-rater data was calculated for the whole data-set as well as subgroups to ascertain inter-rater agreement

Results

86 practitioners responded, giving >2000 individual case responses. Overall agreement was moderate at 67.9% with a kappa of 0.59 [CI 0.49,0.69].  Despite subgroups of paramedics (kappa 0.63 [CI 0.53,0.72]), doctors (kappa 0.61 [CI 0.52, 0.69]) and those with disaster experience (kappa 0.62 [CI 0.52, 0.71]) suggesting slightly higher agreement, their CIs (and those of other subgroups) suggest overall similar and moderate levels of practitioner agreement in classifying severity of injury.

Conclusions

An inter-rater agreement of 0.59 is considered moderate, at best, however it gives MoHs some sense of how tightly they may interpret injury data derived from daily reports using the WHO EMT MDS.  Similar studies, with weighting for injury likelihood using sample data from true SODs would further refine the level of interrater agreement to be expected. Consequently MoHs may develop appropriate frameworks of resource allocation during SODs.



AJNJ is undertaking a PhD funded by the Royal College of Emergency Medicine & Hong Kong Jockey Club Charities Trust however JCS and FL have no funding sources to declare.
Dr Anisa Jabeen Nasir JAFAR (Manchester, ), Jamie C. SERGEANT, Fiona LECKY
15:50 - 15:55 #18320 - SP082 Understanding the perceptions of emergency physicians and general surgeons with regards to the diagnosis, management and the use of POCUS in acute cholecystitis.
SP082 Understanding the perceptions of emergency physicians and general surgeons with regards to the diagnosis, management and the use of POCUS in acute cholecystitis.

INTRODUCTION: 

Patients presenting with acute cholecystitis to the emergency department will often have to wait for a diagnostic radiology performed ultrasound (US). Point of care ultrasonography (POCUS) with targeted images of the gallbladder has the potential to assist in early identification and expedite management. Our objectives are to identify the clinical features and the potential role that POCUS may have for emergency physicians (EPs) and general surgeons (GS) in the diagnosis of acute cholecystitis in the emergency department.

 METHODS: 

An electronic survey with questions relating to diagnosis, management and use of biliary POCUS in patients with acute cholecystitis was devised. The survey was pilot tested by two EPs and two GS. Staff EPs and GS at an urban academic hospital were invited to participate in the survey using a modified Dillman method as part of a quality improvement project. Descriptive statistics were used to analyze the data.

 RESULTS:

The response rate for EPs was 76% (59/78) and GS was 68% (17/25). Both EPs and GS used a constellation of clinical signs and symptoms, laboratory and radiological investigations for the diagnosis of acute cholecystitis. Only 22% of EPs and 18% of GS were confident in interpreting US images for acute cholecystitis with most not reviewing or interpreting radiology performed US images in the course of patient care. Although most EPs (95%) utilize POCUS in their daily practice, only 39% of EPs perform biliary POCUS, citing limited exposure and training and non-acceptance by GS as main barriers to use. None of the GS perform biliary POCUS themselves and 70% did not feel comfortable using biliary POCUS to diagnose acute cholecystitis. In three different clinical scenarios involving patients presenting with acute cholecystitis in the emergency department with POCUS findings presented, over 80% of ACS respondents were willing to accept consultation from EPs while awaiting radiology US and 44% were willing to admit in a typical scenario prior to radiology US with only one GS willing to take to the OR without radiology US. GS identified the following that would improve acceptance of POCUS in the diagnosis of acute cholecystitis - improved training and decreased operator variability, access to POCUS images, and clear written interpretation of POCUS images on the medical record, recognizing that POCUS is not a replacement for pre-operative imaging but to improve ED length of stay (LOS) and expedite ED management.

 CONCLUSIONS:

Our survey has identified important clinical and imaging features for the diagnosis of acute cholecystitis in the emergent setting by EPs and GS, especially with regards to expectations and perceptions of the use of biliary POCUS. Both EPs and GS have identified a willingness to incorporate POCUS for patients with acute cholecystitis to potentially improve ED LOS. Quality improvement initiatives that include education, training, and change in work processes can now be directed to incorporate POCUS in the diagnosis of acute cholecystitis for both EPs and GS.


Dr Bao Yu Geraldine LEONG (Singapore, Singapore), Peter GLEN, Edmund KWOK, Brandon RITCEY, A SHEIK, Michael WOO
15:55 - 16:00 #18575 - SP083 An initiative to improve the quality of point-of-care testing within critical care settings by targeting the pre-analytical phase.
SP083 An initiative to improve the quality of point-of-care testing within critical care settings by targeting the pre-analytical phase.

Background

Availability of rapid and high quality test results offered by Point-of-care testing (POCT) speeds up clinical decision making in critical care settings.  POCT sampling and analysis is usually performed by non-laboratory staff with varying levels of experience. Several pre-analytical pitfalls can dramatically reduce the quality of the POCT result, regardless of the analytical quality of the test.

Aim

Present study aimed to identify pre-analytical challenges of POCT within critical care settings.

Methods

Issues influencing the quality of the POCT result - apart from the analytical quality - were collected during focus conversations and in-person consensus meetings with POCT experts from different European countries and different professional backgrounds (clinical laboratory, ICU, nursing).  

Results

Main areas identified in the pre-analytical phase were: patient and user safety, user and analyser related errors, timeliness expressed as turn-around-time (TAT), training and competence testing of the user, connectivity and over-all quality of the test result (apart from the analytical quality).

The specific challenges in these areas were further detailed. 

Patient safety is negatively impacted by human errors such as incorrect identification of the patient or incorrect ethnography assessment, by blood & sharps exposure, and by delayed, incomplete or erroneous data transfer.  User safety is impacted by blood and sharps exposure.

Human and material errors reported by instruments lead to wasted samples and test materials and cause sample recollection and retesting, prolonging the TAT. TAT is also negatively impacted by high complexity testing. A prolonged TAT negatively impacts patient waiting time and time to medical decisions, thereby decreasing the effectiveness of the test and also has a negative impact on staff time and workflow, thereby decreasing efficiency and increasing working costs.

The most important key factor defining pre-analytical quality is training and competence of the user.  Training and (re)certification of POCT users should be provided by the laboratory’s POCT coordination team.  Lab support frees users of practical and logistical issues concerning POCT such as analytical quality issues, follow-up of lot numbers, expiry dates and quality controls.  POCT coordinators are lab experts trained to provide this support.  Higher user-friendliness of the equipment decreases the necessary training.

Connecting POCT instruments to the Lab Information System and the Electronic Health Record of the patient is an essential contributing factor to correct patient and user identification and to full traceability of the POCT result.

Quality of the test result is negatively impacted by incorrect procedures, such as waiting too long to test the sample, incorrect filling of sampling devices, insufficient sample, haemolysis, improper mixing, improper air evacuation.   

Suggested measurable key performance indicators for the pre-analytical phase are instrument down-time and percentages of incorrect patient and user ID’s, no-result samples, instrument error codes, out-of-control QC results, interventions by POCT coordinator and manufacturer.

Conclusion

We conclude that this initiative has identified several pre-analytical key factors determining the over-all quality of POCT.  A future study is planned to measure the above-mentioned key performance indicators for the pre-analytical phase in real-life critical care settings.



This study was funded by BD UK LTD, Wokingham, Berkshire, RG41 5TS, United Kingdom
Pr Viviane VAN HOOF (Antwerp, Belgium), Suzanne BENCH, Antonio BUÑO SOTO, Antoine GUILLON, Peter LUPPA, Ulf Martin SCHILLING, Annette THOMAS, Andrei N TINTU
16:00 - 16:05 #18902 - SP084 Prevalence of cause and unnecessary emergent brain Computed Tomography (CT) scan among patients with non-penetrating head trauma; A cross-sectional study.
SP084 Prevalence of cause and unnecessary emergent brain Computed Tomography (CT) scan among patients with non-penetrating head trauma; A cross-sectional study.

Introduction: Prevalence of brain injuries is estimated at about 200 people per 100,000 in developed countries and more than 500 people per 100,000 in the United States. CT scan is in fact a selective method for evaluating patients with skull trauma. More than 98% of hit-head imaging did not have positive finding. This study aimed to evaluate the frequency of CT scan requests without indication in patients with head trauma in Rasoul–e Akram, Firoozgar and Haft-e-Tir university hospitals.

 

Methods: In this cross-sectional study, patients who were referred to our hospitals with chief complaint of head trauma, during study period, were retrospectively assessed for eligibility. Patients were selected through hospital information system (HIS) and using consensus sampling method. Demographic information of patients as well as signs, symptoms and brain CT scan results were recorded in a predesigned checklist. In the present study, considered brain CT scan indications were resulted from integration of Canadian CT Head Rules, NICE Head Injury Guideline, ACEP Clinical Policy (Rosen) and New Orleans Criteria guidelines.

 

Results: Eventually 464 (322 male and 142 female) patients were investigated. Mean age of patients was 35.11±18.3 years old and mean GCS score at the time of primary assessment was 14.46 ±2. Fourty-five patients who were referred or attended to our hospitals did not have intended indications but CT scan was requested for them. Finally 86 cases did not have indications for CT scan among which 41 cases were correctly diagnosed by physicians and CT scan was not performed on them.

 

Conclusion: In conclusion the result of the present study revealed that about 11% of performed CT scans in trauma patients are unnecessary and without related indications.

 


Dr Mahdi REZAI (Tehran, Islamic Republic of Iran), Neda ASHAYERI, Farzaneh BEIGMOHAMMADI, Mohammadhosein GHAFOURI ABBASABADI

Tuesday 15 October

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EPOSTER 5.2
15:45 - 16:05

ePoster 5.2 - Short Oral Presentation - Screen 2

Moderator: Felix LORANG (Consultant) (Jena, Germany)
15:45 - 15:50 #18898 - SP085 Ceftriaxone Usage in the Academic Emergency Departments: Evidence Based Utilization or overuse.
SP085 Ceftriaxone Usage in the Academic Emergency Departments: Evidence Based Utilization or overuse.

Introduction: Ceftriaxone is being used, widely, these days, and it is less according to the current guidelines. The aim of this study was to determine the appropriate usage of ceftriaxone. Considering the results may help looking for a way to prevent its inappropriate use in Emergency Department (ED).

Methods: In an observational-analytical study, the patients referred to EDs of two teaching hospitals since September 23, 2017 to March 19, 2018 who have been treated with ceftriaxone, were analyzed. The rational usage of ceftriaxone was determined based on latest evidence based literatures.

Results: Ceftriaxone had been prescribed properly in 156 patients (38.4%; 95% CI, 33.5-42.9%) and its use did not meet logical criteria in the rest of cases consisting of 250 patients (69.6%; 95% CI, 57.1-66.5%). Logical use of ceftriaxone was independently related to treatment-goaled use, level I triage, urinalysis (U/A) compatible with urinary tract infection (UTI), and chest radiographic evidence of pneumonia.

Conclusion: Our study revealed a range of appropriate use of ceftriaxone not acceptable for a teaching medical center; more education seems to be necessary in this field.


Dr Mahdi REZAI (Tehran, Islamic Republic of Iran), Hasan SAFEHIAN, Neda ASHAYERI
15:50 - 15:55 #19043 - SP086 Risk Stratification and Age-Adjusted D-Dimer Test: Are They Satisfactory in Acute Pulmonary Embolism?
SP086 Risk Stratification and Age-Adjusted D-Dimer Test: Are They Satisfactory in Acute Pulmonary Embolism?

PURPOSE: Pulmonary embolism (PE) is associated with high morbidity and mortality and often has a nonspecific clinical presentation. The use of diagnostic testing to reduce the risk of missing a potentially life-threatening diagnosis increases both the cost of care and the use of medical resources. Various score systems exist to evaluate the probability of PE, which can also be used for risk stratification to obtain the most accurate diagnosis. The aim of our study was to review the evidence for existing prognostic models in acute PE and determine their validity and usefulness for predicting patient outcomes. We also determined the accuracy of an age-adjusted D-dimer threshold to detect PE.

METHODS: The study involved the retrospective application of an age-dependent D-dimer cut-off (age/100 in patients aged >50 years) in 659 consecutive patients, both in and outpatients, aged ≥18 years who had undergone CT pulmonary angiogram for suspected PE according to the European Society of Cardiology (ESC) guidelines. We included individuals who presented to an emergency department with a suspicion of PE and who were then referred for objective testing; all participants included were capable of providing informed consent. This study was performed in three emergency departments in Hungary between January 2016 and September 2018. We retrospectively collected information regarding symptoms (dyspnoea, unilateral leg swelling, and haemoptysis), vital signs, and medical and social history (cancer, recent surgery, medication, history of deep vein thrombosis or PE, and chronic obstructive pulmonary disease). We calculated test characteristics, including sensitivity and specificity. We applied three different D-dimer approaches to the low and moderate-probability patients. The primary outcome was exclusion of PE with each D-dimer approach, while the secondary objective was to estimate the negative predictive value for each rule. Data were analysed using SPSS 24.0 statistical software.

RESULTS: In the 659 cases (407 women and 252 men), a total of 105 D-dimer assays, 51 CT angiograms, and 212 chest X-ray examinations were carried out redundantly; if these procedures were not carried out, it could have saved money for the hospitals and reduced radiation exposure for patients. The age-adjusted D-dimer threshold was more specific (70% versus 60%) but less sensitive (95% versus 98%) than risk stratification. The sensitivity of the combined technique (risk stratification and age-adjusted D-dimer test) was 100%.

CONCLUSION: Our study showed that Geneva score (which was calculated from the patients’ complaints, medical history, and physical examination) had the closest correlation with the true diagnosis. An age-adjusted D-dimer limit has the potential to reduce the need for diagnostic imaging and is more accurate than the standard threshold of 500 ng/dL. The combination of risk stratification and age-adjusted D-dimer can be used to safety diagnose PE. Finally, we can conclude that risk evaluation in acute PE is indispensable and the appropriate use of guidelines results in lower healthcare costs. Our data support the use of age-adjustment and perhaps adjustment for other factors also seen in patients evaluated for PE.


Attila PANDUR (Pecs, Hungary), Balint BANFAI, Agnes PANDUR-SARKANY, Henrietta BANFAI-CSONKA, Bence SCHISZLER, Jozsef BETLEHEM, Balazs RADNAI
15:55 - 16:00 #19058 - SP087 Adjustment of Early Warning Score by clinical assessment to improve detection of acute deterioration in hospitalized patients, a feasibility study.
SP087 Adjustment of Early Warning Score by clinical assessment to improve detection of acute deterioration in hospitalized patients, a feasibility study.

Background: Serious Adverse Events in hospitalized patients, such as unanticipated admission to Intensive Care Unit and cardiac arrest, are often preceded by deteriorating vital signs. Early Warning Scores (EWS) are used to allow detection of deterioration. EWS systems is implemented based on the strong association between vital sign abnormalities and poor outcomes shown in several retrospective studies. Only few studies have examined the clinical impact of EWS.

Individual Early Warning Score (I-EWS) is a newly developed track and trigger system where the assessment of vital signs by EWS is combined with a clinical assessment of the patient. This combination has in a previous randomized study improved triage of acutely admitted patients. Prior to comparing I-EWS to the already implemented National Early Warning Score (NEWS) in a prospective cluster-randomized crossover multicenter study, a feasibility study was performed.  The aim was to test the use of I-EWS in a clinical setting and to explore the nursing staff’s experience with I-EWS.

Methods: We performed a feasibility study of the implementation of I-EWS. I-EWS is integrated as a mandatory part of the electronic health care journal. Vital signs are registered, and an aggregated score calculated. Nursing staff is asked to revise the score based on their clinical assessment. The score can be adjusted with a maximum of -4 or +6 points or kept unchanged if the score matches the patient’s clinical presentation. We recorded the number of I-EWS scores and the proportion of up- and down adjustments of the scores. A questionnaire was sent electronically to the staff subsequently to assess the level of information about I-EWS and the applicability of I-EWS. As well as to assess the nursing staff’s perception of I-EWS as a track and trigger system. Data was collected at Herlev and Gentofte Hospital, a 949-bed University Hospital in the Capital Region of Denmark. Eight medical and surgical wards with a total of 250 beds used the I-EWS for a 2-week period in June 2018. Ambassadors from every ward, participated in an introduction course prior to initiation of the study. The Ambassadors introduced their colleagues to I-EWS.  

Results: We recorded 5669 observations during the study period. I-EWS was used in 4585 (80.9 %) of the observations by the end of the second week. Of these scores 876 (19.1 %) were downgraded and 116 (2.6 %) were upgraded. Eighty-one of the 181 questionnaires (45%) were returned and 65.4% were very satisfied/satisfied with the level of information and 16 % answered neither nor. 80.3 % found the registration of I-EWS easy. Less than 6.7 % found no clinical relevance of I-EWS.

Conclusions: The possibility to adjust EWS was feasible and well received among hospital staff. The effect of I-EWS being tested in an ongoing multicenter study that is ongoing.



The feasibility study was not registered, but the following clinical multicentre study is registered at clinicaltrials.gov NCT03690128. The study has received grants from the following: Herlev and Gentofte University Hospital The Foundation of Director Kurt Boennelycke and wife Ms. Grethe Boennelyckes The Gangsted foundation Candys Foundation The Research Council of the Capital Region of Denmark
Pernille B. NIELSEN (Copenhagen, Denmark), Martin SCHULTZ, Caroline LANGKJAER, Niels Egholm PEDERSEN, Anne Marie KODAL, Michael Dan ARVIG, Christian S. MEYHOFF, Bibi HØLGE-HAZELTON, Morten BESTLE, Gitte BUNKENBORG, Anne LIPPERT, Ove ANDERSEN, Lars Simon RASMUSSEN, Kasper K. IVERSEN
16:00 - 16:05 #19383 - SP088 An observational study of older adults admitted to the head injury ward.
SP088 An observational study of older adults admitted to the head injury ward.

An observational study of Older adults admitted to the head injury ward

 

Introduction

 

Head injuries in the older adult population are an increasing presentation to the emergency department as a result of an aging population. The cause of injuries can be more complex in the frail older adult, require further investigations and multidisciplinary input to facilitate safe discharge home.

 

Our department at the Royal Alexandra Hospital (RAH) in Paisley, Scotland serves a population of approximately 200,000 people with approximately 750 beds.  The RAH has a dedicated ward for head injuries managed by Emergency Department (ED). consultants. It provides inpatient observation of patients unsuitable to discharge home from the ED who have sustained a head injury. Patients can be admitted who do not require a CT scan, a normal CT result, or who have sustained an intracranial bleed which does not require operative input after discussion with neurosurgical colleagues.

 

This ward aims to manage symptoms, observe those without social support and discharge patients within 48 hours. Patients with clear other care needs are admitted under the appropriate speciality. Presentations of frail older adults are the most complex to manage and ensuring appropriate care by the right team can improve patient outcomes in this group.

 

We wanted to determine if the cohort of frail patients are inappropriately admitted under the care of the ED as they do not meet criteria from initial presentation that would allow discharge within 48 hours due to increased care needs.

 

Methods

 

This retrospective cohort study reviewed medical notes of all patients aged over 65, admitted to the head injury ward over a 1-year period (Jan 2018-Jan 2019).

 

Frailty was assessed using the F.R.A.I.L screening tool. A patient is deemed frail if there is evidence of:  functional impairment due to significant co-morbidity, a care-home resident, documented acute confusion, impaired mobility, or require increased support on discharge.

 

Results

 

116 patients were admitted and reviewed, the median age was 79.(Minimum 67 and maximum 98 with an average of 79) Average length of stay on the head injury ward was 1.94 days.

 32/166 patients were referred to a different inpatient speciality following admission to the head injury ward.

45/116 of patients were regarded as frail. Their average length of stay was 2.6 days and 15/45 were referred to other specialities compared with 1.52 days and 17/71 respectively in the non-frail group.

 

 

 

Discussion

 

We found 95/116 patients over 65 admitted to our head injury ward were appropriately admitted and discharged within 48 hours. However, 40% were described as frail when using the frailty scoring tool. Notwithstanding a degree of hindsight bias, the results show that this cohort have a prolonged LOS and require subsequent transfer to another speciality during admission.

 

Head injuries in older adults can be the result of disequilibrium in a complex, frail patient and the use of frailty screening tools in the ED can help identify those patients requiring specialist input from elderly care teams rather than admission to a short stay ward and subsequent transfer.


Emma CLARK (Glasgow, United Kingdom), Jonathan RITCHIE, Christopher DALE, Jennifer COCHRANE

Tuesday 15 October

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EPOSTER 5.3
15:45 - 16:05

ePoster 5.3 - Short Oral Presentation - Screen 3

Moderator: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
15:45 - 15:50 #18611 - SP089 Victims of the road accidents at the Emergency Room of Sibiu.
SP089 Victims of the road accidents at the Emergency Room of Sibiu.

Background:

Road Accidents cause the occurrence of a large number of victims in Romania,  trauma cases specifically requiring medical teams starting from Mobile Emergency Service for Resuscitation and Extrication, to complex surgery and the Intensive Care Teams. This aspects led to the need for a study, which emphasises several important elements, of the cases in the last three year. Thus, we used criterions like mainly pathology, the age and the annual distribution of the victims, area where the car crashed, association of alcohol consumption and the state in which the patient was brought to Emergency Room of Sibiu.

Methods:

We conducted a retrospective observational study on a total of 189.397 patients presented at the Emergency Room of Sibiu County Emergency Clinical Hospital, between 01.01.2016 and 31.12.2018.

Results:

From the total of 189.397 patients, in the Emergency Department were reported 1084 victims of road accidents.

We examined how many pacients were brought in the Emergency Trauma Room every year and the results are:

2016 - 401 (36,99%) victims

2017 - 311 (28,69%) victims

2018 - 372 (34,31%) victims

The age distribution during the study was the following:

Age category 18-20 years old:   31 cases (2,85%)

Age category 21-30 years old: 298 cases (27,49%)

Age category 31-40 years old: 210 cases (19,37%)

Age category 41-50 years old: 209 cases (19,28%)

Age category 51-60 years old: 145 cases (13,37%)

 

We were interested to assess the areas from which patients were brought in the Emergency Room and the results are:

Urban Area: 738 (68,08%)

Rural Area:  346 (31,91%) 

 

369 (34,04%) Patients had suffered cranio-cerebral trauma of which:

210 (56,91%) associated one or multiple Contusions

108 (29,26%) were Poly-Traumatized 

 

17,80%, meaning 193 victims, drunk alcohol before driving and had positive results using Breath Test. 

 

Discussion & Conclusions:

The main category of patients injured in crashes is included in the age range between 21 and 30 years old, mostly because lack of preventive behavior.

Although not statistically representative, it is clinically significant that a fairly large number (about one third) of victims presented cranio-cerebral trauma, so we can conclude the fact that vehicles, even if equipped with modern safety systems, are still not prepared to efficiently protect the cephalic extremity, which is actually the most exposed area of the body in the case of road accidents.

There are still situations when drivers are choosing to drive despite having consumed alcohol before.

The large number of victims brought to the Emergency Room from the Urban Area is primarily due to heavy traffic in the crowded cities.


Cristian ICHIM, Ana Daniela ŢĂRAN, Iulia ANDREI, Maria-Ioana OANA-ALBU (Sibiu, Romania), Ştefania Noemi OPRIŞ, Răzvan - Marius DOBRE, Diana - Ionela CHECIU
15:50 - 15:55 #18660 - SP090 Low dose of inhaled Methoxyflurane: more effective and rapid-acting than standard analgesic treatment, also for severe trauma-related pain: subgroup analysis of a randomised controlled trial (InMEDIATE).
SP090 Low dose of inhaled Methoxyflurane: more effective and rapid-acting than standard analgesic treatment, also for severe trauma-related pain: subgroup analysis of a randomised controlled trial (InMEDIATE).

Background

Currently available analgesic options for severe pain in the emergency setting have limitations such as the challenging safety profile of opioids and limited efficacy of weaker analgesics. Inhaled methoxyflurane is an easy-to-administer, rapid-acting, non-narcotic analgesic that has been used in emergency settings in Australia and New Zealand since the 1970s and is now approved in Europe. InMEDIATE was a pragmatic trial in Spanish emergency units (including one pre-hospital unit) that compared the pain relief achieved with methoxyflurane versus standard analgesic treatment (SAT, administered according to each site’s own analgesic protocol).; we report results of a subgroup analysis in patients with severe pain (NRS ≥7).

 

Methods

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a Phase IIIb, open-label, randomised controlled trial conducted from July 2017 to April 2018 by the Pain Group of the Spanish Society of Emergency Medicine/Spanish Clinical Research Network. At triage, eligible patients with moderate-to-severe trauma pain (score ≥4 on the Numeric Rating Scale [NRS]) were randomised 1:1 to receive inhaled methoxyflurane (up to 2´3mL) or SAT whilst in the unit. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Primary efficacy endpoint was change in NRS pain intensity, co-primary endpoint was time to onset of pain relief and patient/clinician-reported outcomes were secondary endpoints. The treatments were compared for the severe pain subgroup (NRS ≥7; N=165) in an exploratory manner using 2-tailed t-tests.

 

Results

The methoxyflurane group included 89 patients, mean age 47.8±19.8 years, 55% male. The SAT group included 76 patients, mean age 45.6±17.9 years, 47% male; 86% received non-opioid analgesia (mostly intravenous NSAIDS) and 13% received opioids. Main injury types were contusion (N=96), fracture (N=43) and swelling (N=27). Mean NRS pain intensity at baseline, 3, 5, 10, 15 and 20min was 8.57±0.82, 6.73±1.70, 5.73±1.91, 4.59±2.19, 4.02±2.32 and 3.32±2.23 for the methoxyflurane group and 8.68±0.78, 8.08±1.38, 7.56±1.70, 6.70±1.91, 5.87±2.30 and 5.20±2.47 for the SAT group. The decrease from baseline was significantly larger for methoxyflurane than SAT at all time points (p<0.001), with the largest treatment difference at 10min (-2.11; 95% CI: -2.75, -1.47; p<0.001). Methoxyflurane-treated patients first reported pain relief at a mean of 6.13min compared with 11.58min for SAT (difference: -5.45min; 95% CI: -8.27, -3.02min; p<0.001). Mean time to first meaningful pain relief was 13.34min for methoxyflurane and 27.38min for SAT (difference: -14.03min; 95% CI: -19.01, -9.06min; p<0.001). Patient satisfaction (scored out of 10) was significantly greater for methoxyflurane than SAT for efficacy (difference: 1.19; 95% CI: 0.59, 1.80; p<0.001) and comfort (difference: 0.77; 95% CI: 0.00, 1.54; p=0.05), and similar for safety. Methoxyflurane exceeded patient/clinician expectations of treatment in 73%/67% of cases compared with 45%/28% for SAT. Adverse events were reported for 31 (35%) methoxyflurane-treated patients (mainly dizziness) and 5 (7%) SAT-treated patients.

 

Conclusions

Methoxyflurane may be considered as an easy-to-use, rapid-acting, first-line alternative to opioid and other analgesic treatments for patients experiencing severe trauma pain.



EudraCT: 2017-000338-70; NCT03256903 / Study funded by Mundipharma Pharmaceuticals S.L.
Cesareo FERNÁNDEZ ALONSO, Dr Sergio GARCÍA COLLADO (Valladolid, Spain), César CARBALLO CARDONA, Rosa CAPILLA PUEYO, Ignacio PÉREZ TORRES, Pere LLORENS SORIANO, José Ramón CASAL CODESIDO, María ARRANZ BETEGÓN, Luis AMADOR BARCIELA, Aitor ODIAGA, Anselma FERNÁNDEZ TESTA, Jorge TRIGO COLINA, Antonio CID DORRIBO, Isabel LÓPEZ ISIDRO, Susana TRASEIRA LUGILDE, Alberto M. BOROBIA PÉREZ
15:55 - 16:00 #18809 - SP091 Prognosis value of geriatric trauma outcome score in senior severe trauma patients.
SP091 Prognosis value of geriatric trauma outcome score in senior severe trauma patients.

Background : Severe trauma is a life threatening situation and is widely described in young patients. Therefore, only few studies were interested in evaluating prognosis in senior trauma patients. Moreover, mechanisms of trauma in elderly  are not as so high velocity-related as in younger patients .This situation could expose to an undertriage of trauma. Fewer scoring tools were proposed in literature. The aim of this study was to evaluate the value prognosis of one Senior trauma score: Geriatric Trauma Outcome score ( GTO Score) to predict mortality at day 7 in aged severe trauma  patients

Methods : it was a prospective study with inclusion of trauma patients aged over 65 years. GTO score was evaluated. Prognosis value towards mortality at Day-7 was studied by characteristics of ROC curve.

Results:  A total of 65 patients was included from the cohort of 699 severe trauma patients admitted to the emergency department during the study period.  Characteristics of the population : mean age = 74 ± 6 years; Mean Injury Severity Score = 23 ± 15; Mean GTOS = 133 ± 38; need of vasocative agents n=16 (25%); massive transfusion in the first 24 hours n=2 (3%); Mortality rate was = 32 % ( n= 21) at Day 7. GTOS was statistically higher in non survivors compared to survivors senior patients : 160 ± 45 versus 120 ± 27 with p < 0,001. Characteristics of the ROC curve of GTO score to predict mortality at Day7 were: AUC = 0,790; p <0,001; CI[95%] = [0,667-0,913]; cut-off = 139; sensitivity = 71% ; negative predictive value 84% )

Conclusion : In this study, GTO score was predictive of mortality at day 7 post severe trauma in senior. Further comparisons with other specific scoring tools is whereas necessary to a better evaluation and emergency field application


Badr FERJEOUI, Imen MEKKI (Tunis, Tunisia), Hamed RYM, Hana HEDHLI, Maaref AMEL, Rym BEN KADDOUR, Safia OTHMANI, Sarra JOUINI
16:00 - 16:05 #18913 - SP092 The incidence rate of death resulting from meningo cerebral lesions (LMC).
SP092 The incidence rate of death resulting from meningo cerebral lesions (LMC).

BACKGROUND

Considering the substantial number of death resulting from meningo cerebral lesions, we aimed to track the causes that led to these lesions and the number of death. These autopsies were performed at Medical Examiner Service( SJML) Sibiu between 2014-2018.

MATERIAL AND METHODE

The current retrospective research is made on a total of 1814 autopsies, performed at SJML Sibiu, between the period of 1 january 2014 – 31 December 2018. From this total, 243 had meningo cerebral lesions.

 

RESULTS

From a total of 1814 autopsies, performed at SJML Sibiu, the number of meningo cerebral lesions was 243, which represents 13,39 %, being distributed as follows: in 2014- 53 patients (21,82%), in 2015- 45 patients (18,51%), in 2016- 46 patients (18,93%), in 2017- 49 patients (20,16%) and in 2018- 50 patients(20,58%).

From these medical situations 104 (42,80%) came from the urban area and 139 (57,20%), from the rural area, and in terms of their gender distribution: 179 (73,66%) are man and 64 (26,34%) women.

During the study, patients with LMC was divided into aged groups as follows: 8 (3,30%) < 18 years, 72 (29,60%)- 19-39 years-, 101(41,57%)- 40-59 years-, 46 (18,93%)- 60-79 years-, 16 (6,60%) >80 years.

During the study, the causes that led to these lesions were: road accident - 103 (42,40%), railway accident- 18 (7,40%), forest accident – 11 (4,52%), falling out from the same level or height - 82 (33,75%) and aggression- 29 (11,93%).

 

CONCLUSIONS

Our research based on a 5-years period of study reveals that the number of patients with LMC during the autopsy in significantly higher to men compared to women and the number of rural patients is predominant.

Most patients fall into age groups: 19-39 (29,60%) and 40-59 (41,57%).

Most frecvently causes that led to LMC are road accidents and falling out from the same level or height.

The number of death caused by LMC is from 2015-2018 in continuous growth.


Ramona Andreea GANEA (SIBIU, Romania), Andreea GANEA, Raluca RUIAN, Adela FARAIAN, Denisa VINTILA

Tuesday 15 October

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EPOSTER 5.4
15:45 - 16:05

ePoster 5.4 - Short Oral Presentation - Screen 4

Moderator: Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, Belgium)
15:45 - 15:50 #18957 - SP093 New method to evaluate an oxygenation for emergency patients who cannot measure SpO2 at the scene.
SP093 New method to evaluate an oxygenation for emergency patients who cannot measure SpO2 at the scene.

Introduction: There are some critical ill patients who cannot measure oxygen saturation (SpO2) by pulse oximeter at the pre-hospital settings. For example, among emergency patients who were treated by emergency medical service (EMS)personnel of Osaka Municipal Fire Departmentin 2016,there were 3,571 patients who had urgent conditions judged by on-scene EMS personnel but did not have cardiopulmonary arrest (CPA), but the measurement of SpOat the scene could not be measured for 395 patients. On the other hand, the measurement of cerebral regional oxygen saturation (rSO2) during resuscitation has been recently paid to attention.

Purpose: To evaluate whether rSOcould be measured for these patients.

Materials and methods: We developed portable rSOmonitors (weighs 600 g and can be carried easily by hanging it around the neck) and equipped them in nine ambulances (There are 63 ambulances in Osaka City). We measured serial changes in cerebral rSOamong emergency patients who had urgent conditions judged by on-scene EMS personnel and could not be measured SpOat the scene from April 1st 2018 through March 31th 2019. “SpOcould not be measured at the scene” was defined as patients in whom SpOcould not be measured for at least 30 seconds from one finger and after attempting measurement on at least two or more fingers at the scene.

Results: During the study period, there were 14 patients who had evaluated serial changes in cerebral rSOwith incapable-measurement SpOwho had urgent conditions judged by on-scene EMS personnel but did not have CPAat the prehospital settings. In many cases, rSOvalues were lower than normal but stable. There are two cases, rSOvalue rose by the ventilation support of the EMS personnel. 

Discussions: Even when SpOcannot be measured, maintenance of a constant value of rSOsuggests that oxygen supply and demand in the brain are stable. Monitoring of cerebral rSOis very useful for EMS personnel under the condition EMS could not evaluate their effort for patient’s by SpO2.

Conclusions: We could measure serial changes in cerebral rSOamong 14 patients without the measurement of SpOat the scene. Our data suggest that pre-hospital monitoring of cerebral rSOmight be a new physiological monitoring for urgent patients during transport.



This work was supported by JSPS KAKENHI Grant Number JP19H03758.
Dr Sakai TOMOHIKO (Suita city, Japan), Shiozaki TADAHIKO, Tachino JOTARO, Takegawa RYOSUKE, Ohnishi MITSUO, Shimazu TAKESHI
15:50 - 15:55 #19064 - SP094 Time from Emergency Medical Service contact to neurosurgical admission for patients with spontaneous subarachnoid haemorrhage – a retrospective cohort study.
SP094 Time from Emergency Medical Service contact to neurosurgical admission for patients with spontaneous subarachnoid haemorrhage – a retrospective cohort study.

Background: Longer time to neurosurgical admission may increase mortality and morbidity for patients with spontaneous subarachnoid haemorrhage (sSAH).

We aimed to determine the time from first telephone contact to the Emergency Medical Services (EMS) in Copenhagen to admission to a neurosurgical department. Secondly, to determine if the absence of the textbook symptom “thunderclap headache” was a predictor for late admission.

Methods: This retrospective cohort study was performed in March 2019. From the Danish National Patient Register data were extracted on all patients aged 18 years or older, admitted to any hospital in the Capital Region of Denmark between May 1, 2011 and December 31, 2014 with a primary discharge diagnosis of sSAH. Medical record review was performed to verify diagnoses. Time of the emergency telephone call was extracted from the EMS-database. Predictors for late admission to the neurosurgical department were analyzed in a logistic regression model adjusting for age and sex. Time interval was reported as median with inter-quartile range (IQR) and range. Proportions and odds ratios (OR) were reported with 95% confidence intervals (CI). Late admission was defined as being above the median value.

Results: Of 262 patients admitted with sSAH, no information was found on admission pattern in 96 patients, 34 patients had been admitted via general practitioners, and one was excluded due to a non-transparent pattern of admission. Thus, 131 patients had called either the European emergency number 1-1-2 or the non-urgent medical help line in Copenhagen both operated by EMS Copenhagen.

Data on initial hospital arrival were available for 119 patients and information about neurosurgical admission was available for 124 patients. Data on symptoms at the time of contacting the emergency telephone line was available for the period May 1, 2011 thru December 31, 2013 for 98 of the 102 patients admitted through the EMS.

Median time from EMS contact to neurosurgical admission was 207.5 minutes (IQR 147-305, 37-5,634). Eighty-six (72.3%, CI: 63.3-80.1) patients were initially admitted to a hospital without neurosurgical facilities and secondarily transferred. For these patients, the median time from arrival at the referring hospital to neurosurgical admission was 186.5 minutes (IQR 128-328). In comparison, in a hospital with neurosurgical facilities, the corresponding time interval between arrival to the hospital and admission to the neurosurgical department was 85.0 minutes (IQR 73-111). Seventeen (17.4%, CI: 10.4-26.3) patients had presented to the emergency telephone line with thunderclap headache. The crude OR for late admission in the absence of thunderclap headache was 5.1 (CI: 1.3-19.3). Adjusting for age and sex, the OR was 4.66 (CI: 1.2-18.1), p=0.0259.

Discussion: We found a median time from initial EMS contact to neurosurgical admission of 207.5 minutes in patients with spontaneous subarachnoid haemorrhage. The absence of thunderclap headache was a predictor for late admission.



ClinicalTrials.gov ID: NCT03786068. Ethics committee approval was not needed. Funding was received from the Danish foundation Trygfonden.
Asger SONNE (Copenhagen, Denmark), Jesper B ANDERSEN, Vagn ESKESEN, Frans B WALDORFF, Freddy LIPPERT, Nicolai LOHSE, Lars S RASMUSSEN
15:55 - 16:00 #19111 - SP095 National Estimates of Marijuana-related Poison Center Calls.
SP095 National Estimates of Marijuana-related Poison Center Calls.

Background: Marijuana is one of the most frequently used illicit drugs in the United States (U.S.) with 7.3% of the population above 12 years of age reporting marijuana use in the past month. Several U.S. states have legalized and regulated the use of marijuana for recreational purposes. The objective of our study was to evaluate the trends in marijuana calls to the U.S. poison centers (PCs) since these regulatory changes were undertaken.

Methods: The National Poison Data System (NPDS) was queried for exposures to marijuana from 01/01/12 through 12/31/18 using the generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Marijuana reports from acute care hospitals (ACHs), emergency departments (EDs), and overall calls including the public were evaluated as a subset. Trends in marijuana frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: During the study, there were 49,268 toxic exposures to marijuana that were reported to the PCs. The frequency of marijuana exposures increased by 209.4% (95% CI: 202.5%, 216.5%; p<0.001), and the rate of exposures increased by 227.1% (95% CI: 193.8%, 265.9%; p<0.001). Of the total marijuana calls, the proportion of calls from ACHs and EDs decreased from 66.1% to 60.9%, with the percentage of calls from the general public increasing. Multi-substance exposures accounted for 59.2% of the overall marijuana calls and 70% of calls from ACHs and EDs. Approximately 15% of the patients reporting marijuana exposures were admitted to the critical care unit (CCU), with 9% of patients being admitted to a psychiatric facility. The residence was the most common site of exposure (83.4%). Cases were predominantly male (58.7%), with the most common age group being 13-19 years (27.1%). The reports for young children under 12 years of age (6.2% to 19%) and older adults above 60 years (3.5% to 7.6%) increased. Intentional abuse (48.1%) was the common reasons for exposure, with the proportions of suspected suicides being higher in cases reported by ACH (20.3% vs 26.9%). During the study period, the proportion of reported marijuana abuse exposures decreased (50.3% to 35.3%), while unintentional exposures increased (11.4% to 22.4%). Major effects were seen in 5.6% cases and there were 223 deaths reported, with 10 fatalities reported for single substance marijuana exposures. The most frequently co-occurring substances associated with the cases were alcohol (16%) and benzodiazepines (15.7%).  Tachycardia (27%) and agitation (17.5%) were commonly observed clinical effects.

Conclusions: Our study results demonstrate a significant increase in the reports of marijuana exposures made to the PCs. The timeline of this study coincides with changes in federal and state laws regarding medical or recreational marijuana use in many states. The exposures in the adolescent age group increased which might be attributed to the unsafe storage practices of adults. Continued surveillance and public health prevention efforts are key to track the population effects of marijuana legalization.  



n/a
Saumitra REGE (Charlottesville, VA, USA), Marissa KOPATIC, Heather A. BOREK, Dr Christopher HOLSTEGE
16:00 - 16:05 #19342 - SP096 How do We manage Superficial Venous Thrombosis? Altamira Study: Observational study in Spanish Emergency Departments.
SP096 How do We manage Superficial Venous Thrombosis? Altamira Study: Observational study in Spanish Emergency Departments.

BACKGROUND

Traditionally, superficial venous thrombosis (SVT) has been considered a benign disorder. It is known that it shares risk factors with deep venous thromboembolic disease (VTE) and therefore a risk of serious thromboembolic complications. There is no an homogeneus consensus in the diagnostic and therapeutic management of patients with SVT. Our objective was to describe the characteristics of patients diagnosed with SVT and their management in the emergency departments (ED) of Spain.

METHODS

Multicentric, retrospective, observational study with all patients diagnosed of SVT, during the period between January 2016 and May 2017 in 18 spanish ED.

Inclusion criteria were patients with diagnosis in ED of SVT in lower limbs, excluding those who presented an indication for anticoagulant treatment for any other pathology.

 The collected variables were demographic, characteristics of patients, comorbidity, VTE risk factors and the diagnostic and therapeutic management in the ED. Also, we collected any complication (recurrence or extension of SVT, deep venous thrombosis (DVT) or pulmonary embolism (PE)), haemorrhage or death in the next six months after SVT. In order to identify independent variables related to the decision of perform an ultrasound and prescribe anticoagulation by the physician, a multivariate analysis was carried out.

RESULTS

A total of 1202 patients were recruited, 67.4% of them women. The mean age was 59.55 ± 16.85, 24.5% had previous VTE, 4.6% active cancer, 2.4% a BMI> 30, and 50% had a history of varicose veins in lower limbs. 39.4% had hypertension and 26.5% diabetis. The median number  days of symptoms was 4 days (interquartile range (IR) 2-7), 50.7% had signs of SVT, being painful cord the most frequent (50.4%). 13.6% had symptoms of DVT. Only 0.5% had clinical symptoms of pulmonary embolism (PE). Only 56.7% underwent ultrasound. 927 patients (77.1%) received anticoagulant treatment with a median of 22 days (RI 10-30). Enoxaparin was the most used, 79.3%. 9.1% suffered a complication in the first six months, being SVT recurrent the most frequent (4.6%). The median number of days to complication was 77 days (RI 19-153). 84.3% had received anticoagulant treatment at diagnosis but only 22% were on anticoagulant treatment at the time of complication. The independent variables associated with the anticoagulation decision were previous VTE [OR 1.5 (95% CI (1.082-2.255); p <0.014)], history of varicose veins [OR1.440 (95% CI (1.079-1.920); p <0.013 )], SVT signs [OR1.42 (95% CI (1.059-1.882), p <0.018)], limb pain [OR1.572 (95% CI (1177-2.098), p <0.002)] and the performance of doppler ultrasound [OR2.241 (IC95% (1680-2988), p <0.001)].

CONCLUSIONS

SVT has an important incidence of complications. The diagnostic and therapeutic management is heterogeneous. The present study evidences that 84% of the patients with complication had received anticoagulant treatment, but 22% remained on anticoagulation at the time of the complication. The duration and/or intensity of anticoagulation for SVT patients in real clinical practice might be suboptimal. 



- This study did not receive any specific funding. - Trial Registration: 17/393-E - This study was approved by the hospital ethics committees involved.
Fahd BEDDAR (Spain, Spain), Sonia JIMENEZ, Jose Maria PEDRAJAS, Lorena CASTRO, Marta MERLO, Ana María PEIRÓ, Angel ALVAREZ, Laura LOZANO, Angel SANCHEZ, Pedro RUIZ

Tuesday 15 October

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EPOSTER 5.5
15:45 - 16:05

ePoster 5.5 - Short Oral Presentation - Screen 5

Moderator: Marco BONSANO (YEMD Communication Lead) (London, United Kingdom)
15:45 - 15:50 #18003 - SP097 The modified bougie as conduit to magnet guided intubation optimized with industrial grade materials performed on cadaveric specimen.
SP097 The modified bougie as conduit to magnet guided intubation optimized with industrial grade materials performed on cadaveric specimen.

Background: We show further evidence for clinical utility of the modified bougie as a conduit for magnetic intubation.  This technique has been demonstrated in theory, subsequently optimized with industrial grade materials on an airway mannequin.  We presented preliminary work at the 2018 European Society for Emergency Medicine 12th Congress. The purpose of this study is to advance understanding through application of the same technique and equipment on four cadaver specimens. 

Methods: We obtained the following: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Hillman Group Ook 18 Guage Steel Galvanized Wire, DdFeB, Grade N52 DISC Magnet NiCuNi Plating Magnet to a Steel Plate: 377.6 Pound Pull Force, 2 dia x 2 thk (in), MAC blade laryngoscope, standard trauma shears, four cadaveric cephalus and torso specimens.  We used shears to cut the bougie at the 55 mark.  The guide wire was fully inserted.  Anatomy was visualized with the MAC blade.  The magnetic field was applied to the distal bougie in the cadaveric oropharynx and hypopharynx with navigating magnet via a location anterior to the cadaver neck.  We confirmed anatomic location via fluoroscopy and sensation of tracheal rings. 

Results: Magnet assisted anterior navigation of the bougie coude tip was obtained in the hypopharynx facilitating passage through the vocal cords into the trachea of each cadaveric specimen.  We replicated prior experience with this magnetic intubation technique on a mannequin in four cadavers.

Conclusion: The authors’ understanding of this unique magnetic intubation technique with industrial products has expanded beyond prior theory and use in the mannequin.  Inability to control the coude tip of the bougie as an adjunct tool for the difficult airway increases the likelihood of surgical airway.  Application of a magnetic field to control endotracheal instrumentation could be a useful tool in the difficult airway algorithm through expansion of existing device functionality.  Successful application in this limited sample of four cadavers suggests further study is important to better understand the magnetic intubation technique and its potential for future clinical utility.



This study did not receive any specific funding.
Matthew VASEY (Tampa, USA), Tiffany VASEY, Angus JAMESON, Derek PUPELLO
15:55 - 16:00 #18901 - SP099 QIP- Procedural Sedation in ED.
SP099 QIP- Procedural Sedation in ED.

Objectives

To implement in ED Procedural Sedation RCEM guideline in order to improve patient’s safety. The first audit was  completed over the  period from 19th of November 2018 to 31st of january 2019, results from documentation pre-procedure, procedure and post-procedure being calculated. The necessity of this QIP arose when an 2017 Audit regarding documentation of procedural sedation in our department  revealed non-compliance with RCEM guideline regarding this procedure.As part of this project, A File for"Procedural Sedation" was set up in Resus containing: RCEM guideline for procedural sedation, a new designed Sticker to be applied on the front page of the patient's notes with inscription "Procedural sedation", a table for patients details for auditing, 3xpages booklet to be completed with patient assessment(airway assessment ,fasting status,etc), patient's consent, vital signs of the patient, pre and post-procedure leaflet to be given to the patient. nasal capnography set up in Resus airway trolley. Monthly teaching performed in order to promote this project.

Results                              

From 33 patient who should have had procedural sedation, 16 patients had the procedure.Documentation improved from 0% to 48.48%. From the patient with documented pre-procedure, improvement were found in: ASA documentation(from 0% to 75%), prediction difficult airway(from 0% to 87.5%), documentation fasting status(from 0% to 68.75%), documentation informed consent (from  37% to 100%), pre-procedure leaflet given( from 0% to 100%),; documentation procedure in Resus(from 46% to 75%), documentation staffing performing the procedure(from 0% to 87.5%), documentation capnography ( from 0% to 12.5%), when oxygen was given( from 0% to 25%),  post-procedure leaflet (from 0% to 62.5%), documentation discharge suitability( from 0% to 37.5%).

Discussion

It is room for improvement for documentation oxygen time / quantity administered, capnography monitoring, documentation discharge suitability, which will be recorded on the second audit in progress.

A second audit is in progress at the moment. Because the usage of the nasal capnography is not satisfactory, teaching regarding the capnography usage was attached to the monthly teaching for this project. The final QIP presentation  will use a PDSA( Plan-Do-Study-act) model for improvement, measuring the documentation of the pre-, post and procedural patient's management. A Gunt and Run charts will be calculated at the final writing paper of this project. 

At the moment a Poster is planned to be placed in RESUS with pictures of the File and capnography and a meeting with a second speciality is in place, in this context Anaesthetics, in order to seek for help in managing the airway for Procedural sedation Project.



n/a
Dr Nicoleta CRETU (Leicester, United Kingdom), Megan KELLY
16:00 - 16:05 #19248 - SP100 Prognostic value of leukoglycemic index in acute exacerbation of chronic obstructive pulmonary disease: A prospective observational study.
SP100 Prognostic value of leukoglycemic index in acute exacerbation of chronic obstructive pulmonary disease: A prospective observational study.

Background: Several biological markers are used to predict poor outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Each of Glycemia and white blood count are known as predictive factors of poor outcomes in AECOPD. The combination of the two could have more sensitivity and specificity value ; The aim of our study was to evaluate the prognosis value of leukoglycemic index( LGI )in patients admitted to the emergency department (ED) with AECOPD.
Methods: Prospective observational study over one year. Inclusion of patients admitted to the ED with AECOPD. The primary endpoints were the need for mechanical ventilation (MV), and 30-day mortality. Test performance was assessed using the area under the receiver operating characteristic curve.

Results: 120 patients were enrolled. Mean age was 63 +/-8 years. Men n (%) was 64 (52, 9). Mean LGI was 12, 10 +/- 7, 14. The LGI area under the receiver operating characteristic ( ROC ) curve (AUC) for the use of (MV) and for the one –month mortality were respectively: 0,74 ;p=0,01;IC 95% [0,58- 0,90] and 0,83;p=0,000; IC 95% [0,69- 0,96]. The best prognostic cut-off value for LGI was 8. In univariate analysis LGI > 8 was associated to 2.1 threshold risk of MV (p=0.001; IC 95% [1.386-3.528] and 4.4 threshold risk of death (p=0.001; IC 95% [1.497-8.839]).
Discussion & Conclusions:
Despite the relatively small number of patients and the fact that the study was conducted only at one hospital, our findings might assist the risk stratification
of AECOPD in the ED, contributing to a better management .At the same time, further medical complications as a result of downgrading the risk of patients with AECOPD in the ED could also be avoided. The LGI is a good prognostic index easy to calculate with a good prognostic value . It can predict poor outcomes during the acute exacerbation.


Hadil MHADHBI (Pontoise), Khédija ZAOUCHE, Yosra YAHYA, Abdelrahim ACHOURI, Abdelwaheb MGHIRBI, Hamida MAGHRAOUI, Radhia BOUBAKER, Kamel MAJED
16:10

Tuesday 15 October

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A34
16:10 - 17:40

Geriatric emergencies
Providing better care for older ED patients
Geriatric, HOT TOPIC SPEAKER!

Moderators: Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, Canada), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
16:10 - 17:40 Geriatric principles in the care of the older ED patient. Simon. P. MOOIJAART (Internist-geriatrician) (LEIDEN, The Netherlands)
16:10 - 17:40 HOT TOPIC !!! How to create a geriatric ED. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, Canada)
16:10 - 17:40 Older people in the ED: Usual care vs. Optimal care. Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, United Kingdom)
CONGRESS HALL

Tuesday 15 October

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B34
16:10 - 17:40

Disaster medicine
Hospital safety
Disaster medicine, Mass casualty, Violence

Moderators: Sofie PAUWELS (Consultant) (Brussels, Belgium), Evert VERHOEVEN (consultant) (Etterbeek, France)
16:10 - 17:40 Cybersecurity. Dr Jeffrey FRANC (Clinical Professor) (Edmonton, Canada)
16:10 - 17:40 Recovery of hospital functions after mass casualty incident. Pr Pinchas HALPERN (department chair) (Tel Aviv, Israel, Israel)
16:10 - 17:40 Violence towards personnel. Eric REVUE (Chef de Service) (Paris, France)
FORUM HALL

Tuesday 15 October

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C34
16:10 - 17:40

Breaking the waves
What is the future of emergency ultrasound?

Moderators: Laila ALAWI HUSSEIN (Specialist Emergency Medicine) (AbuDhabi, United Arab Emirates), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
16:10 - 17:40 AI in POCUS - Artificial Intelligence or Actually Incompetent? Dr Christopher YAP (Consultant) (Sheffield, United Kingdom)
16:10 - 17:40 How to use CEUS in the emergency department. Beatrice HOFFMANN (Boston, Germany)
16:10 - 17:40 US simulation - from high to low cost. Nils Petter OVELAND (Doctor) (Stavanger, Norway)
SOUTH HALL 3AB

Tuesday 15 October

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D34
16:10 - 17:40

YEMD - Innovation in EM - check this out!
From the cutting edge directly to you!
Fringe, Innovation, Young Emergency Medecine

Moderators: Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, Croatia), Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, Belgium)
16:10 - 17:40 Alternatives to aBGA - better, faster...? Stefano MALINVERNI (Emergency Consultant) (BRUSSELS, Belgium)
16:10 - 17:40 High flow nasal oxygen! Bojana RADULOVIĆ (Emergency medicine specialist) (Zagreb, Croatia)
16:10 - 17:40 Follow me into the twittersphere. Dr Dinka LULIC (Resident in Emergency Medicine) (Zagreb, Croatia)
16:10 - 17:40 Squeeze the aorta where it hurts. Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
SOUTH HALL 3C

Tuesday 15 October

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E34
16:10 - 17:40

NURSES
Emerging topics in emergency nursing
Nurses

Moderators: Thorsteinn JONSSON (RN, MS) (Reykjavik, Iceland), Emmanuel ROHRBACHER (INFIRMIER) (MONCONTOUR DE BRETAGNE, France)
16:10 - 17:40 Operations research & simulation: a case study. Dr Kris BRAEKERS (Assistant Professor) (Hasselt, Belgium)
16:10 - 17:40 Pediatric sedation by nurses in the ED. Koen VANHONSEBROUCK (Nurse Specialist) (Leuven, Belgium)
16:10 - 17:40 Preventing Occupational Exposure to Health Care Workers in the ED. Eftychia POLYZOGOPOULOU (ASSISTANT PROFESSOR OF EMERGENCY MEDICINE) (ATHENS, Greece), Saskia VAN KEMSEKE (MPharm) (Brussels, Belgium)
CHAMBER HALL

Tuesday 15 October

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F34
16:10 - 17:40

ABSTRACTS SESSION

Moderators: Pr Abdelouahab BELLOU (Research) (Boston, USA), Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, Belgium)
16:20 - 16:30 #18105 - OP092 Tetanus prophylaxis: are we doing it right? About vaccines.
OP092 Tetanus prophylaxis: are we doing it right? About vaccines.

Background: Patients presenting to the Emergency Department (ED) with wounds prone to tetanus infection, are administered prophylaxis according to specific guidelines, which are based on the immune status of the patient. In some Hospitals, the immune status of the patient can be known through the use of a Point of Care Testing (POCT), the Tetanos Quick Stick (TQS). However, several studies demonstrated that tetanus prophylaxis guidelines were correctly followed only in a minority of the EDs.

 

Methods: This study takes into account the data of 4248 patients who referred to the ED of the Brugmann University Hospital between January 2017 and December 2018, with wounds potentially at risk for tetanus infection. 

Results: In the 12 months of 2017, 2800 patients presented with wounds; of these 2800 patients, 915 were not protected against tetanus infection, while 1885 were still immunized. 

In the 6 months of 2018 which were taken into account, 1448 patients presented with wounds; of these 1448 patients, 426 were not protected against tetanus infection, while 1022 were still immunized. 

Therefore, in the overall period, out of 4248 patients, 1341 patients were not protected by an active immunity against tetanus infection. 

Out of these 1341 non-protected patients, 213 did not receive the vaccine, and were therefore left unprotected. 

On the other hand, out of the 2907 who were already protected by active immunity, 12 patients received an unmotivated vaccine dose.

 

Discussion and Conclusions: These results underline either the incompliance with the prophylaxis administration guidelines or the difficulty in understanding which prophylaxis should be administered. We observed that in some cases, the healthcare practitioners tend to interpret positive tetanus tests as negative ones, and this could be due to the tendency of wanting to be on the “safe” side, and not wanting to commit any error. However, when we administer useless vaccine doses to patients who are already protected, we are committing an error in terms of costs and of patients’ safety, since we need to remember that no prophylaxis comes without possible side effects. 

In order to avoid type 1 errors (incorrect rejection of the true null hypothesis that the patient is vaccinated, and therefore administering a further vaccination dose) and type 2 errors (failure to reject the false null hypothesis that the patient is vaccinated and therefore not administering the needed vaccine dose, which in this context is of course more dangerous), could be done through a better training of the healthcare providers on the TQS results and on its reliability.



Non clinical work This study did not receive any specific funding.
Gaia BAVESTRELLO PICCINI (Bruxelles, Belgium), Jean-Christophe CAVENAILE
16:30 - 16:40 #18248 - OP093 Assessment of overdiagnosis and overtreatment in emergency department from three recommendations Choosing Wisely: a French multicentric retrospective study .
OP093 Assessment of overdiagnosis and overtreatment in emergency department from three recommendations Choosing Wisely: a French multicentric retrospective study .

Introduction : Choosing wisely (CW) is an international initiative to avoid overdiagnosis and overtreatment. In partnership with professional societies, CW develops and identifies recommendations of potentially avoidable prescriptions. We evaluated the number of avoidable examinations or treatments prescribed in 3 Emergency Departments (ED) in Ile de France Region, using 3 CW recommendations. Our hypothesis was that, in France, the percentage of potentially avoidable prescriptions was around 20%, as described in the literature.
Our first aim was to evaluate the prescription of a potentially low value test in a ED. Thus, our hypothesis was that a potentially avoidable prescriptions represented a loss of patient time in the ED.

Methods: This was a multi-centric retrospective review of medical record for patients who visited the ED of two academic hospitals and one regional hospital between the 1st of January and the 31st of December 2016. We examined a random sample of patients aged 15 to 65 years old, who consulted either for non traumatic low back pain, minor head injury or acute sinusitis. For each patient we extracted from the medical record the medical history and clinical examination to assess whether they should have had an exam prescription or a treatment according to CW recommendations. We also assessed whether patients were actually prescribed lumbar imaging, brain imaging or antibiotic therapy to determine the number of potentially avoidable prescriptions. Data are described with median and interquartile (IQR) for quantitative variables and number (%) for qualitative variables.

Results: A total of 1601 patients [43% of women] were included in the study. The median age was 38 years old IQR [28-49]. Consultation motives were low back pain, minor head injury or acute sinusitis for 710 (44%), 679 (43%), and 211 (13%) cases, respectively. A total of 549 (82%), 514 (76%) and 149 (71%) patients with low back pain, head trauma and sinusitis were treated in accordance with the CW recommendations, respectively.
For 70 (10%), 57 (8%) and 39 (8%) patients with low back pain, head trauma and sinusitis, respectively, a prescription could be considered as low value care and could have been avoided. These potentially avoidable prescriptions significantly increased length of stay in the ED for these patients: the subjects for whom an imaging exam was not indicated but obtained, stayed approximatively 5.2h IQR [3.2-9.5], and subjects for whom an exam was not indicated and non obtained stayed 4.3h IQR [2.1-6.8] (p<0.03).

Discussion & Conclusions: Approximately 10% of patients who consult in ED for non-traumatic back pain, minor head injury or acute sinusitis received a potentially avoidable prescription according to the CW criteria. This is the first study in France to evaluate over-diagnosis and over-treatment in the ED, using CW recommendations. Other international studies used administrative database, with more important number of subjects, and the avoidable prescriptions were between 4-40%.
Reducing the avoidable prescriptions in the ED improves the patients’ quality of life and the length of a stay in the ED.



Trial Registration: non clinical work. Funding:“This study did not receive any specific funding.”
Raquel TENA SEMPERE (PARIS), Viet Thi TRAN, Youri YORDANOV, Anthony CHAUVIN
16:40 - 16:50 #18281 - OP094 Evaluation of the development and site-related risks of contrast-induced nephropathy after intravenous contrast media administration: A retrospective cohort study.
OP094 Evaluation of the development and site-related risks of contrast-induced nephropathy after intravenous contrast media administration: A retrospective cohort study.

Background

Intravenous contrast media is frequently administered when using computed tomography (CT) to diagnosis acute critical conditions of patients in the emergency room (ER). Because of the unstable conditions of patients who visit the ER and limitation of accessibility to the medical information of these patients, clinicians sometimes hesitate to use contrast media owing to concerns of contrast-induced nephropathy (CIN). This study’sobjective was to evaluate the development and site-related risks of CIN after intravenous contrast media administration for CT.

Methods

This single-center, retrospective cohort study was performed in a university-affiliated tertiary hospital with an average census of 1,025,110 visits per year. Patients who underwent contrast-enhanced CT (CECT) were included and divided into two groups based on the site of where CECT was executed: the ER group and ward group. Linear regression analysis was used to examine the association between the site of where CT was executed and changes in the serum creatinine level after CECT. Logistic regression analysis was performed to determine whether the site of where CT was executed was associated with the development of CIN.

Results

We investigated 79,849 patients in this study. Overall, 43,037patients underwent CECT in the ER, and 36,812underwentCECT in a ward. CECT performed in the ER was negatively associated with changes in the serum creatinine level (β coefficient -0.01, standard error 0.00, p<0.05) and development of CIN (odds ratio 0.91 95% confidence interval 0.86-0.95, p<0.05).

Discussion and Conclusions

Unlike the general prediction, performing CECT in the ER is not associated with a higher risk of CIN than performing CECT in a ward after admission. Therefore, based on our findings, the weight attributed to potential contrast-induced renal injuries in the clinical decision-making process of clinicians who work in the ER should be adjusted.

 



no appropriate register. This study did not receive any specific funding.
Seungho HAM (Suwon, Korea, Republic of), Joon Pil CHO, Hyuk-Hoon KIM
16:50 - 17:00 #18388 - OP095 Are physicians meeting goals for time from triage to evaluation? A retrospective analysis.
OP095 Are physicians meeting goals for time from triage to evaluation? A retrospective analysis.

Objective. To examine whether physicians adhere to the urgency classification as determined by the Canadian Triage and Acuity Scale (CTAS).

Design and Method. A retrospective-archive study was conducted in a tertiary hospital from January 2011 to December 2015. For each patient, we examined the relation between the urgency rating set by the triage nurse and the waiting time for the physician by using univariate and multivariate analysis. Ccomparisons were performed for several subgroups: patient arrival time, season, assigned care area, and first consultant to examine the patient.

Results. There were 392,687 unique visits during the study period. The distribution of the classification was heterogeneous: 7,133 (1.8%) patients were classified as P1; 17,318 as P2 (4.4%); 148,657 as P3 (37.8%); 113,502 as P4 (28.9%); and 106,077 as P5 (27%). Median and interquartile ranges for time from triage until physician assessment, by triage group, were: P1, 0.7 minutes (0.2-24); P2, 35 minutes (13-76); P3, 44 minutes (21-88); P4, 45 minutes (20-87); and P5, 46 minutes (22-88). Percentages of visits that met the evaluation time goals, by triage classification, were: P1, 61%; P2, 27%; P3, 37%; P4, 61%; and P5, 85%. No clear differences among subgroups emerged.

Conclusion. The standard goals for time to physician evaluation are not being met, and there is little difference in time to evaluation between the P3, P4, and P5 classifications. This is likely because the physicians are not consulting the triage classification when deciding whom to evaluate next. System-wide changes in physician workflow and awareness should be initiated.

 



n/a
Saban MOR, Nadav ARMONI, Heli PATITO, Ari LIPSKY (Haifa, Israel), Aziz DARAWSHA
17:00 - 17:10 #18634 - OP096 Screening for hypertension in adults during emergency department consultation: a systematic review.
OP096 Screening for hypertension in adults during emergency department consultation: a systematic review.

Objective

A large proportion of patients affected with hypertension go undetected. Screening remains a challenge. During an emergency department (ED) consultation, one in three adults has elevated blood pressure. A systematic review was conducted to assess the performance of a screening strategy in adults (positive predictive values, follow-up rates) using blood pressure (BP) measurement at the time of an ED consultation. The secondary objectives are to describe BP measurement methods employed at the time of the initial consultation in the ED and the means used to monitor it, and also to describe the means used to confirm a diagnosis of HTN

Method

A systematic literature search on Embase, CINHAL, and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Diagnostic Test Accuracy (PRISMA-DTA). Intervention studies with non-pregnant adults including at least one BP measurement for all participants were included. A procedure had to have been carried out to assess the validity of the elevated BP value within the next few days of the initial visit.  In order to assess the quality of the studies identified, we adapted the tool Quality Assessment of Diagnostic Accuracy Studies-2 (Quadas-2).

Results

Out of 1,030 articles identified, 10 articles published between 1987 and 2014 met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years (95% CI 46.7 - 56.5 years). A single study reports that BP screening was measured according to all the recommendations from the guidelines. The average follow-up rate was 61.9% (95% CI 45.5 - 78.3). For diagnostic confirmation, four studies used a BP measurement method based on the guidelines.  Half of the patients (50.2% (95% CI 35.9 - 64.45)) with elevated BP during the ED visit had BP corresponding to uncontrolled elevated blood pressure at follow-up measurement.

Conclusion

In the context of emergency care, the measurement of blood pressure is usually performed in a non-standardized way. Despite this, in adults with high BP during ED consultation, half of them will have uncontrolled hypertension confirmed at follow-up. The contribution of ED to the screening for HTN, by making a referral for diagnostic confirmation, could provide a major opportunity to eventually reduce the burden associated with HTN and its complication.



André Michaud has received grants from Ministère de l’éducation et de l’enseignement supérieur du Québec (MÉES), the Réseau de recherche en soins infirmiers du Québec (RRISQ) and the Société Québécoise d’Hypertension artérielle (SQHA) in order to support his PhD studies.
André MICHAUD (Trois-Rivières, Canada), Maxime LAMARRE-CLICHE, Alain VADEBONCOEUR, Lyne CLOUTIER
17:10 - 17:20 #18742 - OP097 A clinical prediction model to identify which children attending the emergency department are at risk for returning with a serious illness after initial discharge: a prospective multicentre observational study.
OP097 A clinical prediction model to identify which children attending the emergency department are at risk for returning with a serious illness after initial discharge: a prospective multicentre observational study.

Objectives:

To study the characteristics of an initial visit of children presenting to the emergency department (ED) that are associated with a revisit with a serious illness, and to develop a clinical prediction model. 

 

Methods:

We performed a prospective multicentre observational study in five European EDs (the TRIAGE study). Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures, and outcomes were collected for consecutive children aged

 

Results:

109,482 children with an index visit were included, of whom 98,561 children (90%) were discharged. 1,026 children (1.0%) returned to the ED with serious illness out of a total of 7,891 representing children (13.0%). Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). 

Characteristics of the index visit associated with a revisit with serious illness included: age (children

A model predicting the risk of a revisit with serious illness based on clinical characteristics had an AUC of 0.73 (95% CI 0.71–0.75). 1,634 children had a risk of >= 5%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 5.65 (95% CI 4.62–6.91) and specificity 0.98 (95% CI 0.98–0.98). 31,876 children had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.25 (95% CI 0.20–0.31), sensitivity 0.92 (95% CI 0.90–0.93)). A model also including intravenous medications, clinical interventions, and laboratory investigations had improved AUC of 0.75 (95% CI 0.74–0.77; p <0.001).

 

Conclusion: 

Multiple characteristics of an index visit were associated with the risk of a revisit with serious illness. We developed a prediction model that can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up. 



n/a
Dr Ruud NIJMAN (London, ), Dorine BORENSZTAJN, Joany ZACHARIASSE, Carine HAJEMA, Paulo FREITAS, Susanne GREBER-PLATZER, Frank SMIT, Claudio ALVES, Johan VAN DER LEI, Ian MACONOCHIE, Henriette MOLL
17:20 - 17:30 #18774 - OP098 Pulmonary Embolism Probability Score (PEPS): derivation and validation of a new probability score in pulmonary embolism suspicion allowing safely reduction of imaging testing.
OP098 Pulmonary Embolism Probability Score (PEPS): derivation and validation of a new probability score in pulmonary embolism suspicion allowing safely reduction of imaging testing.

Introduction:
For patients suspected of pulmonary embolism (PE), several strategies have been developed to limit the use of imaging tests and especially CT-Scan (PERC, YEARS, ADJUST-PE …) and are based on clinical data and threshold values of D-dimers. Each of these strategies is based on a different method of assessing the clinical probability (CP) that limits their combination.
Objective:
Our goal is to derive and validate a single clinical probability score allowing optimization of clinical data and D-dimer measurement and safely reduction of imaging testing.

Methods:
Based on the negative likelihood ratios of D-dimers, four levels of clinical probability were previously defined in order to obtain a strategy with a false negative rate < 1.9%: [1] without D-dimer test (very low CP, false negative <1,9%), [2] with D-dimer <1000 μg/L (low CP, false negative <15%), [3] with D-dimer <500 μg/L or < (age x10) after 50 years (moderate CP, false negative <60%), [4] and a last level (high CP) that can not safely exclude pulmonary embolism on the basis of clinical data and D-dimers.
A derivation and an internal validation cohorts were obtained from four European and American
prospective studies, including 11.066 patients suspected of PE. An external validation cohort was obtained
from a fifth prospective study of 1744 patients.
Statistically significant variables associated with PE in univariate analysis were included in a multivariate
logistic regression model. Points were assigned according to the regression coefficients, constituting the
PEPS score. The score was validated in the internal and external validation.

Results:
The score include 13 variables : age <50 years (-2), age between 50-64 years (-1), heart rate <80beats/min
(-1), chronic respiratory pathology (-1), chest pain and recent dyspnea (+1), male (+2), syncope (+2),
thromboembolic history (+2), immobilization (+2), estrogen therapy (+2), SpO2 <95% (+3), calf pain (+3),
and PE is the most likely diagnosis (+5).
A score <0 corresponds to a very low CP, between 0 and 4 to a low CP, between 5 and 11 to a moderate
CP and ≥12 to a high CP.
In external validation, the prevalence of PE was 11.7% (95% CI: 10.3-13.4) and, for each category, it was
respectively 1.4% (0.6-3.3), 7.2 % (5.7-9.1), 24.9% (21-29.2) and 51.1% (37-65).
The application of the PEPS strategy in the external validation cohort would have resulted in a false
negative rate of 0.85% (0.5-1.5) and 21.4% (19.4-23.5) D-dimer tests reduction and 26.6% (23.5-29.9)
imaging testing reductions.
We compare previous strategies applied to our external cohort and observed a reduction of imaging tests
by 20.8% (18-23.9) for YEARS, 7.8% (6.1-9.9) for PERC, 6.2% (4.7-8.1) for ADJUST-PE, 4.3% (21.4-27.5) for
PERC combined to YEARS, 13% (10.8-15.6) to PERC combined to ADJUST-PE.

Conclusion :
The strategy based on the PEPS score may lead to a safely substantial reduction of imaging testing
comparatively to previous strategies. It should now be tested in an outcome interventional study.


Dr Boris GERMEAU (Brussels, Belgium), Emilie FRIOU, Pierre-Marie ROY, Jeffrey KLINE, Andrea PENALOZA
17:30 - 17:40 #19397 - OP099 PREDICTING 30-DAY MORTALITY OF PNEUMONIA ON EMERGENCY DEPARTMENT SETTING BY MACHINE-LEARNING MODEL.
OP099 PREDICTING 30-DAY MORTALITY OF PNEUMONIA ON EMERGENCY DEPARTMENT SETTING BY MACHINE-LEARNING MODEL.

Background

Pneumonia is still the leading cause of death among infectious diseases worldwide. There has been importance on disposition based on several severity scores. Though many severity scores have been used already, novel machine-learning based models are needed for more accurate predictive power. The aim of this study is to prove effectiveness of machine-learning based model to predict 30-day mortality of pneumonia on Emergency Department setting.

 

Methods

This study was a retrospective analysis of adult medical patients with pneumonia registry on EMR arriving at Samsung Medical Center’s Emergency department(ED), a 63-bed unit, a tertiary referral center in Seoul, Korea from January 1, 2016 to December 31 2017. Patients aged 18 years or order those who have pneumonia registry on EMR was enrolled in the study. We collected data including demographic information, mental status, and laboratory finding. The primary outcome was the 30-day mortality and ICU admission from ED. Clinical factors were analyzed using logistic regression analysis. The ROC curve was fit to the sensitivity and specificity of machine-learning based model for mortality. Machine learning model was developed based on Random Forest(RF) algorithm from a training set, and its performance was evaluated by area under receiver operating characteristic curve (AUROC) from the test set.

 

Results

Of 1,974 pneumonia patients, 1,732 patients were eligible for study inclusion and 1,723 patients were analyzed finally. Of 1,723 patients, 564 were died within 30-day or ICU admission from ED initially. The AUC of CURB-65 was 0.593, and the AUC of novel machine-learning based model by RF was 0.84. The machine-learning model had 91.4% sensitivity, 47.9% specificity, 78.1% positive predictive value and 73.4% negative predictive value.

  

Discussion & Conclusions

Classification by machine-learning based model can help to predict the mortality of pneumonia patients on ED more accurate than pre-existing CURB-65. It also has fewer variables than the model PSI, another predictive tool which has 30 variables, and it is expected to be more suitable for ED setting.


Soo Yeon KANG (Seoul, Korea, Republic of), Junsang YOO, Won Chul CHA, Taerim KIM, Joo Hyun PARK, Hee YOON, Sung Yeon HWANG, Min Seob SIM, Ik Joon JO
TERRACE 2B