Dexmedetomidin is a novel selective α-2 adrenoreceptor agonist with anxiolytic, sedative and analgesic properties that prolongs analgesia and decreases opioid related side effects when used in perineural as a local anesthetics adjuvant. The goal of this study was to test whether it has any effect on pain intensity and opioid requirements when injected perineurally alone.This prospective and double-blind study was conducted in 60 American Society of Anesthesiologist (ASA) class I–II patients undergoing femoral fracture shafts surgery. Based on block permuted randomization, the patients were randomly divided into two groups: D and C, with and without PNB respectively.In the group D ,dexmedtomidine 100 µg, was injected to surround the femoral nerve completely using US guidance. In both groups total postoperative opioid consumption,visual analogue score (VAS) for pain were compared. There was a significant different in postoperative narcotic required in the group D in comparison to the group C. No significant adverse effects were encountered among groups. The mean VAS scores showed a significant different immediately postoperatively and at6,12and 24 hours postoperatively in the group D in comparison to the group C (P < 0.05)For overall patient satisfaction, patients in the group D reported significantly higher mean satisfaction scores than those in the group C .In conclusion perineural administration of dexmedtomidine significantly decreased postoperative pain intensity in the patients undergoing femoral surgery.

INTRODUCTION: acute renal colic (ARC) represents one of the most common causes of abdominal-lumbar pains (2.9%), and nontraumatic diagnosis (1.5 %) of emergency medical conditions. But ARC heterogenic management and inadequate analgesia are frequents. The goals of this study were (1) to evaluate emergency department (ED) practices concerning the use of analgesic drugs for optimal pain control or relief, urine diagnostic tests, and medical imaging techniques in patients with ARC; and (2) to compare this clinical assessment with national recommendations. METHODS: we performed a retrospective study of patients admitted in the ED from January 2012 to December 2013 with a final diagnosis of acute renal colic. RESULTS: during this period 440 ARC in 317patients were enrolled, of whom 213 men (71%), with an average age of 39 years. Sixty-five patients (20.5%) developed ARC recurrence (a total of 123 times) during this period. Concerning the pain intensity, 83% of patients had a score ≥ 5 on admission, using the Visual Analog Scale (VAS: 0-10) or the Numeric Rating Scale (NRS: 0-10). The meantime to pain acute care was 1 hour; but it was < 45 minutes if pain score ≥ 6. Paracetamol was the most commonly used drug for pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs), especially ketoprofen, were prescribed in 49.5% of patients. Morphine as the first choice of strong painkillers was used in only 18% of patients with pain score ≥ 8 on admission, but in 27% of them with score= 10. A NSAIDs-morphine combination therapy was prescribed as first-line drugs of choice in only 11 patients. A urine dipstick test for hematuria was negative in 20.5% of cases. A urine culture was performed in 89% of cases with positive urine dipstick test for white blood cells and/or nitrites: only 16% of them were positives. In spite of the absence of severity criteria, 73% of patients with first-episode ARC had at least one ED imaging test: sonography (42% of patients; ureteric calculi detection: 22%); noncontrast abdominal computed tomography (47%; ureteric calculi detection: 73%). Hospitalization was indicated for 74% of patients with ARC severity criteria. DISCUSSION: the application rate of ARC national recommendations was superior to 80% for almost of them. On the contrary, this rate was inferior to 70% concerning the prescription of NSAIDs (54%) and morphine (36%), and imaging indication in young people. CONCLUSION: The first priority in ARC is to ensure quick and effective relief of pain, but progress still has to be made on this matter. The respect of recommendations would improve the ARC management and diagnosis, and reduce costs and ED stay delay, critical challenges in emergency medicine. 

Background and Objectives

Inserting foley catheter in male urethra is one of most annoying procedures in the emergency departments. Although most of the physicians use Lidocaine gel for alleviating pain and discomfort of this procedure, there are numerous of patients who need foley catheter complaining of its pain and discomfort

This study was conducted to examine the efficacy of local ketamine along with Lidocaine gel for instillation in the male urethra for easiness of urethral catheterization, as compared with using Lidocaine gel alone.

Method

A total of seventy four male patients who were scheduled to undergo urethral catheterization were randomly assigned to receive either 10mL of 2% Lidocaine gel mixed with 1mL normal saline (Lidocaine only group), or 10mL of 2% Lidocaine gel combined with 1mL Ketamine (50mg) (Lidocaine plus Ketamine group). Up to 8 mL of prepared mixture instilled directly into the urethra. Three minutes later by using sterile and standard technique and lubricating the appropriate catheter with whatever remained from the mixture, procedure was done

Baseline characteristics and hemodynamic variables of all patients including pulse rate, respiratory rate and blood pressure were measured before and after insertion of Foley catheter. Level of pain perception of patients at the baseline and after every procedure in both groups was recorded by using the numeric rating scale (from Zero to 10).

Result

There were no significant differences in baseline characteristics and hemodynamic changes between two groups of the patients, before and after the procedure. Although pain of urethral catheterization of “Lidocaine only” group were at tolerable level (NRS= 3.8), it was significantly decreased in “Lidocaine plus Ketamine” group (NRS=1.4)

Conclusion

Instillation of Lidocaine gel in conjunction with Ketamine locally in the urethra could decrease perceived pain and would make men undergoing urethral catheterization more comfortable during the procedure. 

Background: Pain is the main cause of presentation in an emergency department (ED) for patients with sickle cell disease. Due to the atypical presentation of those patients and the high doses of opioids needed to treat them, they are often misunderstood, under evaluated and under treated by the staff. For all those reasons we have written, in collaboration with the hematology department, a protocol including hyper-hydration and high dose of morphine.

Aims: The primary objectives were to evaluate  the management of those patients and the adequacy of this treatment with the written protocol and the pain score defined by the use of an analogic visual scale(AVS) by the patients and by the nurses. The secondary endpoints were an evaluation of the satisfaction of the patients with a questionnaire, measuring an estimated time by the patients between the first contact and the administration of the first dose of analgesic drugs and finally the total dose of opioid given.

Methods: In partnership with the department of hematology, we realized an observational prospective monocentric study, after submission to the ethical committee, concerning the treatment of adult sickle cell disease patients in our ED. This study was performed during two years (from February 2013 until February 2015) . Informed consent was obtained previously during routine visit or in the emergency department when the patients were admitted for vaso-occlusive crisis. Both nurses and patients realized a pain evaluation on admission, with AVS, and the treatment was started using the written protocol. Before leaving the ED, patients received a satisfaction questionnaire  to evaluate their degree of satisfaction. The questionnaire was graded from 1 (very bad) to 5 (very good).

Results: During this period, we registered 70679 consultations in our ED, where we recruited 104 observations (0.15%), reparsed on 51 patients. Mean waiting time was 18,6 minutes between first contact and first dose of analgesic drugs, but the received doses of morphine were significantly lower than those recommend on our protocol. The mean satisfaction score of patient was 3,8.

Discussion: Due to the presence of a protocol, we have noticed that the ED staff was more attentive and reactive to sickle cell disease patients, with a quick evaluation of the pain and a short delay between the first contact and the first dose of analgesic drugs. We also noticed a respect of the hydration program, but an underutilization of opioids,  despite the presence of a specific protocol. However, we obtained a good global satisfaction of the patients concerning their management.

Conclusion: Despite the presence of a specific protocol, we can observe that the management of vaso-occlusive crisis is quite difficult and depends on the partiality of the staff in pain evaluation and the fear to entertain a opioid addiction by those patients. The presence of a written protocol is nevertheless a good point to sensibilize the team about this quite rare affection and formations given to the staff about this rare pathology help to improve the satisfaction of the patients.

RN Helle Ipsen, RN Christina Ørsted Rasmussen, RN Marianne Barylak. Emergency Department the Hospital of Nykobing Falster,

Introduction and purpose

Pain is a frequent cause leading to admission in the Emergency Department (ED,) and pain relief has importance for patient satisfaction. Surveys have shown that patient satisfaction is high, but audits in patient’s journals didn´t reflect this. Therefore, we have studied the gap between patient satisfaction, staff performance and documentation of pain management, to find the basic reason for the disagreement, which have led us to develop and implement a local guideline. The hypothesis was that the documentation only described a minor part of the efforts to treat the patient`s pain, and an altered approach to documentation of pain management would embrace the clinical efforts, and be shown in the patient files.

Materials and methodology

A validated semi structured questionnaire of ED nurses experience and attitude to pain management and their documentation is compared to patient satisfaction. A regional standard demands that all patients with a score > 3 on a Visual Analog Scale (VAS) have a documented plan and follow up of the effectiveness of treatment. Baseline data are results from the national investigation of patient satisfaction and standardized audit on the use of VAS in 77 cases. In the study, 20 nurses from the ED working 2 consecutive days had a questionnaire with 11 questions about how they document and perform pain treatment, and their experience of the barriers to follow the regional standards. In parallel, 20 acute patients were interviewed, and afterwards the documentation of their pain treatment was analyzed. After implementing a local guideline for pain management a follow up audit was carried out. Results are analysed with a mixed qualitative and quantitative analysis and presented as tables. 

Results

Baseline data: 82-87% of the patients in the ED are satisfied with the pain management, and audit shows that 85% of all patients (n=77) have been asked about pain at arrival to the ED.  Of 20 patients with a VAS > 3, audit showed less than 15% of the files contained a plan and follow up procedures for pain treatment. The nurses express a holistic approach to pain treatment using medication as well as non-pharmaceutical skills, but they experience lack of time, uncertainty about their skills in pain management and weak IT support as the main course of their insufficient documentation. Giving the nurses new opportunities to manage the patient’s pain at arrival, and instructions to use the available IT system in an easier way, the quality of documentation of pain management and follow up of the effectiveness of treatment are improved from 15% to 90%.

Conclusion

The study shows that the procedures nurses use to give pain relief might have importance for the patient satisfaction, although it is not demonstrated in their documentation. Giving the nurses policy options for pain management and demonstrating how to use the IT system in a simple way, can reduce the gap between documentation and the performed clinical skills.

Introduction: Nasogastric tube insertion is one of the routine and painful procedures in emergency department. Lidocaine gel is routinely used for analgesia before nasogastric tube insertion. There are growing evidences on local effect of sub anesthesia doses of ketamine in reducing procedures pain without developing systemic effects. This study was designed and performed for comparison of routine nasogastric tube insertion with lidocaine and nasogastric tube insertion using ketamine.

Methods: This prospective double blinded randomized clinical trial was performed on emergency department's patients who were above 18 and without serious concurrent disease. Patients were divided into two groups. We administered 3ml (50mg) intranasal ketamine 5minutes before nasogastric tube insertion in one group and other group patients just received 3ml of distilled water in the same way. Nasogastric tube insertion was done by using lubricant gel in former and lidocaine 2% gel in latter group.

Results: Seventy four patients were enrolled in the study (equally distributed). There were not any significant differences between demographic data in two groups. Pain was significantly lower in ketamine group (visual analogue scale: 38.162 ± 8.398 vs. 57.417 ± 11.193); however there was not any significant difference on difficulty of tube insertion (mean 5 point Likert scale: 2.879 ± 0.451 vs. 2.680 ± 0.500). Complications were nearly same in two groups.

Conclusion: Nasogastric tube insertion using intranasal ketamine produces less pain than using intranasal lidocaine. Ketamine is a safe drug for nasogastric tube insertion in patients without serious concurrent illness. However, nasogastric tube insertion using ketamine is no way easier than insertion using lidocaine.

Background: Children referred to the pediatric emergency department  for suturing a laceration often require sedation in order to lower anxiety and  pain and to induce amnesia.

Objective: To assess the efficacy of oral Ketamine vs oral Midazolam for sedation in laceration repair at the pediatric emergency department

Methods: Children aged 1-10 years with  laceration requiring suturing were recruited at the pediatric emergency department. After obtaining consent from the legal guardian, children were randomly assigned using a computer-generated sequence to one of two groups. One group was treated with oral ketamine 5 mg/kg (maximal dose 70 mg)  and the other was treated with oral midazolam 0.7mg/kg (maximal dose 20 mg). Parents and investigators were blinded to randomization until statistical analysis of the study was completed.

Main outcome measures were level of pain during local anesthesia, as assessed by VAS (visual analog scale) by the parent, and the number of children who failed oral  sedation. Secondary outcomes were VAS by investigator, level of sedation using the UMSS (University of Michigan Sedation Scale), parents and physician satisfaction, length of stay and adverse effects.

The analysis of the data was done by intention to treat and per protocol. Groups were compared  by t-test or Mann Whitney for continuous variables and by Fisher exact test  for categorical variables. The estimated sample size was 26 children in each group.

Results: Eighty six eligible patients were approached and  68 children were recruited. Thirty seven children were allocated for treatment with Ketamine and 31 for Midazolam. Mean age was 5.6 + 2.1 years in children treated with ketamine and 4.5 + 2.1 years in children treated with midazolam (mean difference 1.1, 95% CI 0.05 to 2.1).There were no other differences between groups in the demographic characteristics. Failure to achieve adequate sedation was more common among children treated with ketamine. Twelve (32% ) of the children treated with ketamine required IV sedation compared with only two children (6%) of the children treated with midazolam (p=0.014). Twenty five children treated with ketamine and 29 children treated with midazolam completed the study. VAS by a parent during local anesthesia was 4.8 +3.3  in children treated with ketamine and 3.8 +3 in children treated with midazolam (mean difference 0.96, 95% CI -0.74 to 2.67). Average UMSS in children treated with ketamine and midazolam was  1.6+0.84 and 1.7+0.65  respectively. Average recovery time was 105.08+29.09 minutes in children treated with midazolam  and 98.78+30.63 in children treated with ketamine. There was no significant difference between groups in the physician satisfaction from the procedure  as assessed on VAS.  No serious adverse effects were noted.

Conclusions: In children requiring sedation for laceration repair treatment with 5mg/kg of oral ketamine compared with 0.7mg/kg of oral midazolam resulted in higher proportion of sedation failure. In the doses tested, oral midazolam provide better sedation.

Background: Non-convulsive seizure and non-convulsive status epilepticus (NCS/NCSE) might present with altered mental status (AMS) without any sign or symptom of seizure. Our previous work has revealed that 5% of ED patients with AMS have NCS/NCSE. Since EEG is not routinely available in the ED, most cases of NCS are not diagnosed in the ED. More than 50% of NCS cases are diagnosed more than 24 hours after ED presentation, and usually in the intensive care unit. Objective: To identify the clinical findings that could predict high risk of NCS/NCSE in ED patients with AMS.

Methods: Retrospective analysis of prospectively collected data. Inclusion criteria: Adult ED patients with AMS. Exclusion: Patients with immediately correctable cause of AMS (e.g. hypoglycemia, narcotic overdose). EEGs were recorded upon presentation and were interpreted by on-call epileptologists within one hour of recording. EEGs were recorded either by standard EEG and microEEG (Bio-Signal Group Inc.) or by microEEG alone. Proportions are presented as percentages with 95% CI. Continuous variables are presented as medians and quartiles (25%,75%). Group comparisons are performed with Mann-Whitney U or Fisher’s exact tests, when appropriate (alpha 0.05, two-tailed).

Results: We enrolled 332 patients with AMS (median age: 66 [quartiles: 50,78), 50% male). In total, 16 patients were diagnosed with NCS (5%, 95%CI, 3 - 8%). Only age was significantly different between the NCS vs. Non-NCS groups (p = 0.032). Previous history of seizure was reported only in 63% (95%CI, 39 - 82%) of NCS patients. Only 31% (95%CI, 14 - 56%) of NCS patients had abnormal neurological exam (other than AMS). Among patients who had head CT, only 20% (95%CI, 6 - 46%) had abnormal findings. Because of the small number of NCS cases, performing a multivariate analysis was not possible.

Conclusion: Increase in age is associated with higher risk of NCS/NCSE in AMS patients. There are no other clinically useful variables that could predict or increase the pre-test probability of NCS/NCSE in such patients. ED physicians ought to have a high index of suspicion for NCS/NCSE in ED patients with AMS. EEG should be the standard of care in all patients with undifferentiated altered mental status.

Introduction: Headache are responsible for 2.2% of emergency department visits .Triptans are used as a migraine specific medication to terminate migraine headach attacks . Although triptans have been introduced as asafe and effective treatment for migraine attacks this class of drugs has well known side effects and contraindications.Several studies have shown that subanesthetic doses of propofol areefficacious as rescue therapy for acute migraine headache in adult andchildren.In this study we are comparing the effect of infusion propofol with subcutaneus sumatriptan in treatment of acute migraine headache.

Method: This study is the randomized double blind prospective clinical trial.Ever 35 known migraine paitent meeting the international headache society (IHS) criteria are enrolled in this study and randomly allocated into two groups.In first group 30 microgaram per kilogaram propofol infused in 100cc normal salin in 1 hour with 6 mg sumatriptan subcutaneus injected.In the second group 6 mg sumatriptan subcutaneous injected with placebo.

Result:There are significant differences between the two groups in respons to treatment.The primary outcome (pain intensity) is significant lower 30 minutesafter treatment in group one (pvalue< 0.05). In group one 75% of the paitent had vertigo and sleepy that improved10 minutes  after completion of drug.In second group 66.7% of the paitent had chest tightness. No paitent had hemodynamic instability in both group.

Conclusion: This study has shown that sumatriptan and propofolis  more effective with faster respons and better pain control 30minutes after treatment than sumatriptan and placebo.

Relationship between full outline of unresponsiveness score coma scale and glasgow coma scale of stroke patients in emergency room, siriraj hospital

Surabenjawong U, M.D.*, Sonmeethong W, M.D.*, Prayoonwiwat N, M.D.**, Nakornchai T, M.D.*,

*Department of Emergency Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.

Background: The Full Outline of Unresponsiveness Score Coma Scale (FOUR score), a recent coma score, was developed to solve some limitations of the well-known Glasgow Coma Scale (GCS). From previous studies, FOUR score can predict the neurological outcome in an intensive care and traumatic patients better than GCS. However, there is no report in stroke patients.

Methods: The prospective cohort study was conducted in adult patients, diagnosed with acute stroke in emergency department of Siriraj hospital. Patients with history of previous head injury were excluded. Every patient was evaluated with both FOUR score and GCS by trained emergency physicians. The primary outcome was the correlation between both scores. The Modified Rankin Scale (MRS), Cerebral Performance Category (CPC) and 3-month mortality rate predicted by FOUR score and GCS were defined as the secondary outcomes.

Results: After analyzing data of 60 stroke patients in emergency department, mean FOUR score of the population was 14.05 (SD 4.02) and mean GCS was 12.45 (SD 3.74). FOUR score and GCS had an excellent correlation with r = 0.821 (p value <0.001). With cut-off point for mortality prediction of 10 and 9 for FOUR score and GCS respectively, FOUR score predicted 3-month mortality rate better than GCS with area under the curve (AUC) of 1.00 (p value <0.001, 95% CI 0.94-1.00) while AUC for GCS was 0.99 (p value <0.001, 95% CI 0.92-0.99). FOUR score was also outstanding in predicting the poor neurological outcome (MRS 4-6 and CPC 3-5) with cut-off point of 10 (AUC of 1.00, p value <0.001, 95% CI 1.00-1.00). Meanwhile, the GCS with cut-off point of 9 had AUC for predicting neurological outcome of 0.94 (p value <0.001, 95% CI 0.91-1.02).

Conclusion: FOUR score and GCS had an excellent correlation for evaluating the consciousness in acute stroke patients. FOUR score is not inferior to GCS for predicting 3-month mortality and poor neurological outcome.

Keywords: acute stroke, Full outline of unresponsiveness score coma scale, Glasgow Coma Scale

Background: Acute ischemic stroke (AIS) in children is an uncommon but potentially devastating condition. Prompt recognition is crucial to guide appropriate management in the acute care setting. The gold standard for the diagnosis of stroke is brain magnetic resonance imaging (MRI). Long delays to diagnosis are the most important barrier to thrombolysis in children. This may be a consequence of both delayed presentation to medical attention and in-hospital factors including limited access to diagnostic brain imaging.

Objective: primary outcome was to determine the time to first neuroimaging in children diagnosed with ischemic stroke. Our secondary aim was to identify patient and process factors that contributed to delayed neuroimaging.

Design/Methods: Retrospective study of children with a radiologically confirmed stroke in a tertiary care center, RCH Melbourne, between January 2003 and December 2012. Data on presentations to a referring hospital prior to transfer to our center were also collected.

Results: 71 episodes of AIS and 19 of TIA were recorded. The time from symptom onset to hospital arrival was 2.5h (IQR 1-19) for patients who first presented to another hospital and 3.6h (IQR 1.3-18.5) for first presentations to our center. Overall time from hospital arrival to first neuroimaging was 3.3h (IQR 1.2-8.3). 66% of children received CT as the first imaging modality in a median time of 1.5h (IQR 1.0-3.7), but the scan was only diagnostic in 25% of cases, whilst MRI was the first imaging performed in 34% of cases, in a median time of 3.9h (IQR 1.4-13.7) and it was diagnostic in 100% of AIS. Time to final diagnosis (on either CT or MRI) was 11.3h (IQR 4.1-22.5). Sedation was used in 28% of children (12% of CT scans and 41% of MRI scans). Children who underwent their first scan more than 3h after hospital presentation were more likely to receive an MRI as first neuroimaging modality (OR 10.75, 95% CI 3.56-33.72) and to have a final diagnosis of TIA (OR 7.34, 95% CI 2-33). Use of sedation was not significantly associated with a delay in neuroimaging (OR 1.83, 95% CI 0.67-4.97).

Conclusions: Despite the poor diagnostic accuracy, CT was still the first neuroimaging modality performed in the majority of patients with AIS, often within 3 hours from arrival. MRI had superior sensitivity to CT, but was more likely to be performed beyond this time window. Use of sedation did not seem to be associated with delayed neuroimaging. Development of acute stroke imaging protocol to maximise diagnostic yield in minimum time are urgently needed.

Background: Acute ischemic stroke (AIS) is uncommon in childhood, but recurrent strokes occur relatively frequently (up to 1/3 of the patients), particularly in cases with atherosclerotic arteriopathies and cardiac disease. The gold standard for the diagnosis is magnetic resonance imaging (MRI). Whilst significant delays in the diagnosis have been previously reported in children with a first episode of AIS, recurrences should be recognized earlier and time to final diagnosis reduced.

Objective: To describe the clinical characteristics, time to diagnostic neuroimaging and differences in the acute management of recurrent AIS episodes compared with first presentations.

Design/Methods: Retrospective study in a Pediatric tertiary referral hospial of children diagnosed with AIS between January 2003 and March 2014. Data on presentations to referring hospitals prior to transfer were also collected.

Results: 70 patients were included with a mean follow up of 5.6 years (SD 2.3). Of these, 11 subjects had a total of 23 episodes of recurrent stroke, occurring at a median of 208 days (IQR 37-395) after the index stroke. Patients with a recurrence were older (median age 8.04 vs 6.23 years) and more often females (82.6% vs 55.7%, p=0.021). Recurrent episodes tended to arrive more often by private car and presented with signs and symptoms different to first presentations (less non-focal/diffuse features, like altered mental status and vomit, less focal motor features, like focal limb weakness and dysarthria and more nuanced symptoms, like focal numbness). All the 70 patients with a first AIS underwent neuroimaging, whereas neuroimaging was not performed in 3 recurrent episodes, where a clinical diagnosis of TIA was made after neurology consultation. Computed Tomography (CT) was the first scan modality in 2/3 if first strokes but still the first in 50% of the recurrences, being diagnostic in 17% of cases overall. Time from symptom onset to hospital arrival was not significantly shorter for patients with a recurrence (p>0.05). Time to first and diagnostic scan was significantly longer for patients with a recurrent episode compared with first presentations (respectively p=0.015 and p=0.021).

Conclusions: Knowledge of prior stroke does not seem to have a positive effect on decreasing time delays to arrival at hospital or time to brain imaging. Most recurrent strokes were associated with self-limited symptoms. Despite the low diagnostic accuracy CT scan was still the first neuroimaging performed in half of the recurrent episodes. Development of acute stroke imaging protocol to maximise diagnostic yield in minimum time are urgently needed in children.

Background: In ischemic stroke caused by a thrombosis of a large brain artery, two million neurons, 12 kilometers of axons and 14 billion synapses are lost every minute. IV-thrombolysis (IV-tPA) in such cases appears ineffective, while mechanical thrombectomy (MT) is reported to be a powerful tool to open the occlusion (1). However, the favorable effect of recanalization is highly time-dependent (2). American Stroke Association recommends a door-to-punction time shorter than 120 minutes. At Tampere University Hospital approximately 70 patients per year are presently treated with MT. Since 2013, we have used a validated MT protocol that includes key personnel from paramedics to interventional neuroradiologist. Hence, we wanted to evaluate the current efficacy of our protocol. Previously, consecutive series of patients with door-to-recanalization time of less than 90 minutes on average have not been reported.

Materials and Methods:  From 1.1.-12.4.2015, all consecutive MT patients were identified from our hospital records. We collected the following data: symptom onset time, door-to-punction time, door-to-recanalization time, NIHSS (National Institutes of Health Stroke Scale) at arrival and at 24h post recanalization, and TICI (Thrombolysis In Cerebral Infarction) score 0-3 (0=no flow- 3=complete tissue reperfusion).  A total of 18 consecutive patients (mean NIHSS 17 at arrival, range 6-22) treated with MT were identified, of whom 14 were also treated with IV-tPA.

Results: Our preliminary results show that the median door-to-punction time was 25 minutes (range 14 min – 1h 33min) and the median door-to-recanalization time was 66 minutes (range 30 min – 128min). The median symptom-onset-to-recanalization time was 4 h 40 minutes (excluding 3 wake-up-strokes). Recanalization was not achieved in two patients. The remaining 16 had a minimum TICI score 2b and displayed a favorable outcome at 24 hours (mean NIHSS 6, range 0-19).

Discussion:  Early reperfusion is the main factor predicting good outcome in stroke recanalization therapy. Our current protocol enables systematic high-speed recanalization in patients with proximal brain artery thrombosis. We achieved at least TICI 2b recanalization in 90% of the cases.

References:

1. Berkhemer OA, Fransen PS, Beumer D et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20.
2. Mazighi M, Meseguer E, Labreuche J et al:  Dramatic recovery in acute ischemic stroke is associated with arterial recanalization grade and speed. Stroke. 2012 Nov;43(11):2998-3002.

OBJECTIVE: We aimed to assess the possible correlation between optic nerve sheath diameter (ONSD) measurements on initial brain computerized tomography (CT) images and National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS) and the relationship with mortality in ischemic stroke patients admitted to Emergency Department.
FINDINGS: Total of 143 patients were included to this study. Case group was constituted from 70 patients and the control group from 73. Mean age of the case group (n=70) was 72.1±12.9(32-95), and 51.2% of the patients were female and 48.8% were male. Control group mean age (n=73) was 68.9±10(35-88), 53.7% of the patients were female and 46.3% of the patients were male.There was no statistically significant difference among groups in terms of gender distribution and mean age (p=0.437).The case and control groups were observed having similar comorbidities, however, statistically significant differences were only detected in terms of HT, previous cerebrovascular event and DM risk factors between the case and control groups. Mean ONSD values measured on CT were 5.52±0.76 mm for the right eye and 5.79±0.85 mm for the left eye in the case group and 5.04±0.52 mm for the right eye and 4.95±0.58 mm for the left eye in control group. According to these results, a significant difference was determined between right and left eye mean ONSD measurement values in the case and control group patients (for right ONSD, p=0.01; for left ONSD, p=0.01). Mean hospitalization time of the case group patients were 16.1 days and mean duration of stay in intensive care unit was 13.7 days. Mean NIHSS points of the case group was 9 and mean GCS score was 14. There was no significant difference between survivors and non-survivors in the case group in terms of each eye ONSD values (for right ONSD, p=0.84; for left ONSD, p=0.73).
RESULTS: There is a linear relationship between intracranial pressure and optic nerve sheath diameter meaurement values on unenhanced brain computerized tomography images in ischemic stroke patient population. Final data of our study indicate that ONSD measurement values could be used for prediction of intracranial pressure in ischemic stroke patient population but for the prediction of mortality, ONSD measurement values alone stand insufficient. Optic nerve measurement on brain tomography images can be used as an non-invasive method for detection of increased intracranial pressure in cases where invasive intracranial monitorization is contraindicated or alternative non-invasive monitorization devices such as USG are not availible.

Introduction:

Vertigo is a common complaint of patients who seek care in the emergency department (ED). In terms of signs and symptoms, overlap exists among the many potential causes. The report of symptoms can be vague, inconsistent, or unreliable. Life-threatening disorders can masquerade as benign disorders. What are the main causes of emergency vertigo?

Objective:

To explore the causes of emergency vertigo stratified by age and gender to improve the diagnostic efficiency

Methods:

A prospective observational study was conducted over seven months. All the patients presented to the ED with vertigo were included. The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected. The etiologies were identified and stratified by age and sex.

Results:

Inclusion of 122 patients. Mean age 53  +/- 16 years. Sex ratio = 0.87.  Comorbidities n (%): hypertension 39 (32%), Diabetes 23 (19%), history of vertigo 52 (43%), coronary artery disease 7 (6%), stroke 9 (8%). Mortality was 1%. The top three diagnoses were benign paroxysmal positional vertigo (BPPV in 91 cases, 75%), central vertigo in 13 patients (PCI, 11%) and hypertensive peak in 9 cases (7,4%).

Stratified by age, the main cause of vertigo for the patients < 30 years (N=12) is BPPV (100%). For the patients aged between 30-45 years (N= 30), BPPV was found in 25 patients (83%), central vertigo (n = 2, 7%), iatrogenic cause, hypertensive peak and CO poisoning in one patient each. BPPV (n=26, 75%), psychological factors (n=3, 8%), central vertigo (n=2, 6%), iatrogenic cause (n=2,6%), one patient had cardiac cause and another patient  CO poisoning, for 45-60 years group (N=35). For the group of patients aged between 60-75 years old (N=35), central vertigo was found in 8 cases (23%), BPPV was found in 20 cases (57%), hypertensive peak (n=7, 20%), cardiac cause (n=2, 6%) and psychological factors in one case. For the elderly group > 75 years (N=10), BPPV was found in 8 (80%) of patients, and central vertigo in 1 (10%), hypertension was found in one patient (10%).

Stratified by gender, there was no difference for the main three etiologies: BPPV, central vertigo or hypertensive peak. But psychological factors were more common in women, and cardiac causes more found in men.

Conclusion:

 The main causes of emergency vertigo were: BPPV, central vertigo and hypertensive peak. BPPV should be considered initially when vertigo was triggered repeatedly by positional change, especially for young patients. In elders with vertigo, central vertigo and hypertension were common. In women psychological factors should be considered and diagnosis and treatment should be offered timely.

Glucokinase (GK) plays a key role in the control of blood glucose homeostasis. In the present study, we investigated the effect of ischemic preconditioning (IPC) on immunoreactivities of GK and its regulatory protein (GKRP) following 5 min of transient cerebral ischemia in gerbils. The gerbils were randomly assigned to 4 groups (sham-operated-group, ischemia-operated-group, IPC plus (+) sham-operated-group and IPC+ischemia-operated-group). IPC was induced by subjecting the gerbils to 2 min of ischemia followed by 1 day of recovery. In the ischemia-operated-group, a significant loss of neurons was observed in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) at 5 days post-ischemia; however, in the IPC+ischemia-operated-group, neurons in the SP were well protected. In the immunohistochemical study, immunoreactivities of GK and GKRP in neurons of the SP were distinctively decreased in the CA1, not CA2/3, from 2 days post-ischemia, and hardly detected in the SP at 5 days post-ischemia. In the IPC+ischemia-operated-group, immunoreactivities of GK and GKRP in the SP of the CA1 were similar to those in the sham-group. In brief, our findings show that IPC dramatically maintains immunoreactivities of GK and GKRP in neurons of the SP of the CA1 after ischemia-reperfusion and indicate that GK and GKRP may be necessary for neurons to survive against transient cerebral ischemia.

Purpose: This study aimed to investigate the impacts of thrombolysis and thrombectomy on lymphocyte DNA damage and oxidative stress parameters for the treatment of adult patients with ischemic stroke in early post-stroke period (within the first 4-6 hour of stroke) based on clinical and radiological findings.

Materials and methods: Over a 7-month period (May 2014 through November 2014), 62 consecutive adult patients who presented to the Emergency Department of Bezmialem Vakif University and diagnosed as an acute ischemic stroke were included in this prospective clinical study. Thirty-two patients who met the inclusion criteria and 30 eligible healthy volunteers as control subjects were enrolled. Patients were divided into 3 groups according to their National Institute of Health Stroke Scales (NIHSS) on admission. Additionally, patients were stratified into three different groups based on modified Rankin Scale (mRS) at 24 h after thrombolytic treatment or endovascular thrombectomy. Plasma lymphocyte DNA damage and Total Oxidant Status (TOS), Total Antioxidant Status (TAS) and Oxidative Stress Index (OSI) were assessed in all groups classified with respect to NIHSS and mRS, both on admission and at 24 h after the treatment. The results were compared between the groups.

Results: Plasma TOS and OSI levels and lymphocyte DNA damage were found to be significantly higher, whereas plasma TAS levels were significantly lower in patients with stroke compared with those in the controls (all comparisons, p<0.001). According to the comparison of NIHSS groups with respect to the stroke severity; increased lymphocyte DNA damage levels and decreased TAS levels were observed (p< 0.001 and p=0.034, respectively). When the patients were classified into subgroups with respect to mRS, plasma TOS and OSI levels and lymphocyte DNA damage tended to be higher in group 3 which comprised patients with the most neuronal dysfunction compared to those in groups 1 and 2 (p=0.003, p=0.001 and p=0.006, respectively).

Conclusion: Lymphocyte DNA damage and TAS, as biomarkers of early oxidative changes can be regarded as an objective alternative criterion to the stroke assessment scales for determining severity of brain damage in patients with ischemic stroke. Additionally, lymphocyte DNA damage, TOS and OSI levels as an early biological indicators can help to identify neurologic health and well being and to evaluate the effectiveness of thrombolytic treatment or endovascular thrombectomy in such patients.

The RESPECT EM! (NL) Project

Research Education and Stimulation Program Creating Tomorrow’s Emergency Medicine in the Netherlands

A collaborative effort by the Departments of Emergency Medicine of UCSF/Fresno and Westfriesgasthuis

Introduction

Published scholarly activity by Dutch emergency physicians has markedly trailed the overall development of the specialty of EM in the Netherlands.  In a 2013 Dutch study by Koning et al (1), EM trainees revealed that “scientific research should be facilitated more.”  The same study concluded that, “Even though research and publications are essential to positioning EM as a fully qualified specialty, residents lag behind in a research role.  While they were stimulated to undertake research, they received very little support.”  The same is true for EM trainers, supervisors and faculty members.  Another 2013 study by Ahmed et al found that structured residency research programs are associated with higher resident research productivity and publication rates (2).

Objectives

With this perspective in mind, Westfriesgasthuis EM Residency Directors approached a US-based consultant with research and medical writing expertise.  The thought being that a consultant could quickly and easily “import” research and medical writing capability into an ED primed to receive that knowledge.  A team of resident and faculty physicians was assembled at the Westfriesgasthuis to participate in the project, the endpoint of which is publication of at least one scholarly project by each team member.

Methods

The program’s timeline is 36 months.  It starts with an intensive series of facilitated face-to-face educational sessions.  Early topics to be covered include: research and medical writing – why do it?; problems and blocks to research initiation, progress and completion; research resources; performing a medical literature search; article/publication types; funding one’s project; publication/presentation venues; collaborating with others; framing a publishable project; and statistics.  All participants will have at least one defined publishable project ready to start at the end of this intensive seminar series.  Thereafter, the research consultant will be available electronically to mentor and advise program participants.  Three months after the start, the research consultant will return for face-to-face sessions to further participant’s progress.  Interim progress assessments and project assistance will be provided by the Residency Directors.  As participant’s projects near completion, editing and article submission will be assisted by return on-site visits. 

Conclusion

We see RESPECT EM! as a valuable model for others in EM wishing to spur the development of their own research and medical writing programs.

A descriptive article detailing the RESPECT EM! project will be readied for submission to a scientific journal.

References

(1) Koning SW, Gaakeer MI, Veugelers R. Three-year emergency medicine training program in The Netherlands: first evaluation from the residents' perspective. Int J Emerg Med. 2013;6(1):30.

(2) Ahmad S, De Oliveira GS Jr, McCarthy RJ. Status of anesthesiology resident research education in the United States: structured education programs increase resident research productivity. Anesth Analg. 2013;116(1):205-10.

Background: We evaluate the impact on the throughput process for patients’ with the implementation of a dedicated laboratory POCT Acute Rapid Laboratory protocol (PEARL) in the Emergency Department.

Methods :Comparative study of Turnaround time (TAT) delays for Troponin, Brain Natriuretic Peptide (BNP), D Dimers before and after the implementation of a POCT in ED (41,000 visits/year) during 2 months (Feb-March 2014-2015). We used the Lean process to analyze time to send blood samples from the ED to the Central laboratory : Turnaround Time (TAT), delay for results, impact on Length of Stay (LOS). Patients’ characteristics: sex ratio, age, medical chief complaints, level Triage (Australian Triage Scale), TAT for urgent (routine process) and very urgent for critical ill patients, delay for results and LOS. 

Results: during the same period (01/02 to 31/03) the number of ED visits was similar (+5%) 6748 patients (2014) vs 7354 (2015). We analyzed 1354 vs 1812 blood samples for Tn, BNP and D Dimers. We use lab tests for rapid diagnosis for patients’ chief complaints like chest pain , coma dyspnea with/without an acute respiratory distress, Congestive Heart Failure (CHF)or for patients in the resuscitate room with life threatening conditions (4% of total ED visits).Turnaround Time with POCT was significant (p<0,05) shorter with an average earlier (- 55 to 74,8 mn) for results for Troponin, D Dimers and BNP with the PEARL Protocol (Fig.1) . The average Length of Stay (LOS) was significant shorter (- 55 mn) for patients with Triage Scale Level 1 of severity.

Discussion: Patient’s flow in the ED and the Lean process focus on the throughput model have a significant impact on the timeliness and quality of care in the ED. In literature, Point of Care Testing (POCT) has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. Using POCT, caregivers can perform, analyze, obtain, and act on test results at the bedside significantly faster than if samples were sent out to a central laboratory. If used effectively, POCT has the potential to decrease delays to treatment initiation, increase ED efficiency, optimize transport for blood samples to the Central lab, influence patient care positively and alleviate the negative effects of long waiting times. Close collaboration with the central laboratory Department is necessary to evaluate PEARL protocol’s impact for quality care and on financial cost for patients.

Conclusions: Prolonged waiting times and treatment delays can have substantial effects on patient outcomes . Rapid TATs from POCT represent clinical decision making and a good quality care patient management . When used in the appropriate context, our POCT PEARL protocol reduce delays to treatment initiation in the critically ill, improve outcomes, increase timely patient rates for frequent complaints like chest pain, rapid diagnosis of Myocardial Infarction, Thrombosis or Congestive Heart Failure. Costs of POCT per analysis seem to be outweighed by the total gain of expedited patient flow in the appropriate setting.

Background

In many German hospitals, emergency departments (ED) suffer from crowding effects caused by an extended average length of stay (ALOS single troponin test: 2h 54 min; ALOS serial troponin tests: 7h 12 min). Due to the fact that between 30 % and 70 % of patients entering the ED do not require emergency-status, the waiting times for troponin (cTn) test results of patients with “non-specific thoracic pain” (12 % of ED-patients) are one reason for non-acceptable LOS in the ED. In addition, the variation in the turn-around-time (TAT) between collecting the blood sample and availability of test results fluctuates between 42 and 121 minutes (average TAT = 73 minutes): a non-controlled process with high variance and a blockade of ED resources.

Objectives

The objective of this study was to clarify to what extent a POCT-solution for troponin contributes to avoiding crowding effects and to reducing LOS of ED-patients. Additionally, the impact of how an investment into POCT pays off in terms of reducing staff workload and containing costs was examined. Furthermore, the importance of learning curve effects and the employees' resistance to change were analyzed.

Methods

A randomized single-center trial was conducted at a university-affiliated hospital with 80.000 ED patient visits per year. In the first study phase, cTn measurement of patients with suspicion of NSTE-ACS was performed in a central laboratory setting (62 patients). One week after having implemented a POCT-solution for cTn, another 46 patients were observed in terms of therapeutic turn-around-time (tTAT) and LOS in the ED (second phase). Six months later, the third phase including 48 patients took place. Again, tTAT and LOS were measured and learning curve effects were analyzed. To compare the central laboratory and the POCT-setting, ED-staff who performed POCT (26 people) were queried on different items (e.g. satisfaction with workflow effectiveness; patient risks ) in order to identify resistance to change and the acceptance of the POCT-setting in all three phases of the study.

Results

POCT was associated with an accelerated availability of cTn test results (lab: 72 min; POCT: 15 min), a shorter time to physician notification of cTn level (90 min; 48 min) and a reduced ALOS by 54 minutes. Furthermore, a potential of cost savings between 560 and 1.100 € p.d. was identified.

Conclusion

POCT for cTn measurement has clinical relevance for ED patients with “non-specific thoracic pain,” especially for high-risk patients with a low suspicion of ACS (“late responders”). POCT contributes to reducing “crowding effects,” containing process costs, and increasing patient satisfaction because of reduced ED waiting times. A POCT-setting for cTn measurement is significantly more acceptable to the ED staff than in a central lab setting.

Discussion

A change of setting from central lab testing to POCT in fact means a shift of workload from lab to ED-staff. The employees’ motivation to use a new implemented technology as a part of a new workflow organization is crucial to achieve a high level of effectiveness and efficiency. This level could be leveraged if additional parameters critical to therapy are measured by POCT (e.g. CRP).

Background: Delayed diagnosis and treatment in shock patients may lead to multiorgan dysfunction syndrome (MODS) and eventually death. Volume status assessment in shock patient is a crucial key to guide early management in emergency room. Nowadays, limited echocardiography becomes an important tool to assess volume status because it is non-invasive and easily to perform.

Methods: Cross sectional study was conducted in emergency department, Siriraj hospital from October to December 2014. The patients presented with shock or uncertain volume status were included. All investigators underwent short course training in limited echocardiography, including lecture and workshop. Emergency physicians (EP) performed echocardiography and classified left ventricular function (LVF) into 3 categories; good, moderate and poor contraction. A blind cardiologist re-evaluated all video files and estimated LVF to determine a correlation using kappa statistic.

Results: Ninety-seven patients compatible with inclusion criteria were enrolled. Of these, overall agreement between EP and cardiologist was 79.4% and weighted kappa was 0.73. Percentage of LVF correlation estimation between EP and cardiologist in good, moderate and poor contraction were 62%, 9.8% and 7.6%, respectively. Accuracy in diagnosis pericardial effusion was 100%. The most appropriate view rated by cardiologist was subxyphoid view (94.6%) and the least appropriate view was apical 5-chamber view (70.7%).

Conclusions:  Emergency physician with short training in limited echocardiography can assess LVF by visual estimation with high agreement compare with cardiologist.  

Study objectives: The outcomes on learners of simulated patient death remain controversial. A few studies reported conflicting results, and psychological and cognitive effects on learners are unclear. We sought to assess the impact of simulation-based training with unexpected manikin death on the learners ‘anxiety when facing life threatening situation (LTS).

Methods: We conducted a prospective multicenter randomized trial on teams that work in an emergency department (ED). Each team included a core of one resident, two nurses and one care giver. They participated in a simulation-based training with a scenario of a 35 year old man in the ED with ventricular fibrillation due to a Brugada syndrome. We randomly assigned each team in two groups: after three shocks, the patient returns in spontaneous cardiac activity (life group LG), or the patient ends in asystole (death group DG). To ascertain the death, the learners were told that patient was declared dead after 45 min of advanced life support. Subjects were aware that they participated in a study about emotional responses in the settings of LTS and they were told during the pre-course that manikin’s death was an eventuality. Our primary endpoint was the assessment of anxiety when facing a LTS, evaluated through the State part of the State-Trait Anxiety Inventory (STAI). Participants were asked to fill this questionnaire before, then one month after the course. We recorded data on their satisfaction on a 1-10 scale. We used the paired Student t-test for comparison of parametric data. Gaussian distributed variables are expressed as mean (Standard deviation SD) and non-Gaussian as median [25-75 interquartile range IQR]. We calculated the exact 95% confidence interval (CI) for mean differences.

Results: Forty subjects were included in the pilot study. Five were excluded as they refused to complete the study. Amongst the 35 analyzed participants, they were 22 in the DG and 13 in the LG, including eight (22%) residents, 14 (43%) nurses, nine (25%) care givers and four (10%) medical students. Mean age was 28 years (SD 6) and 71% were women. Median duration of the scenario and debriefing was 14.6 min [IQR 14.4-14.7] and 25.0 min [IQR 22.6-27.1] respectively. Before the simulation training, median baseline STAI score was 45 [IQR 38-51], similar in both groups (45 [IQR 40-52] in LG vs 44 [IQR 36-50] in DG, p=0.36). Median STAI score was significantly improved at one month after the session, with a mean difference of 5.1 (95%CI [2.5 – 7.7]). We report a trend towards greater reduction in the DG, although not significant: 6.1 (95% CI [1.9 – 10.0]) vs 3.5 (95% CI [0.6 – 6.3]) in LG, p=0.30. Satisfaction of the learners was excellent in both groups, with a median rate of 10 [IQR 8 – 10].

Conclusions: Simulation based training on LTS reduced anxiety amongst learners, whether the manikin died or not. We report a trend towards higher stress reduction at one month after a simulated patient death.

Point of Care Ultrasound; Are we practicing safely?

Introduction

Clinicians increasingly use Point of Care Ultrasound (PoCUS) as an adjunct to history and examination to facilitate crucial clinical decision-making. This is frequently seen in Emergency Medicine in the United Kingdom to a degree that acquisition of Level 1 competency in PoCUS is now compulsory for Emergency Medicine higher specialty trainees. However little is known about the scale of use of PoCUS by clinicians, especially in relation to its governance (reporting, recording, storage, supervision/review and audit). Therefore we conducted a survey looking into clinical governance of Point of Care Ultrasound in the Yorkshire and Humber region in the United Kingdom.

Methodology

We conducted a survey within the Yorkshire and Humber region looking in to the governance of Point of Care Ultrasound in Emergency Departments. The questionnaire comprised of questions related to usage and governance.

Results

Out of the 18 Emergency Departments we inquired, 13 replied (72.22%), of which 3 are trauma centres and 6 are trauma units. All departments have US machines with M mode, B mode and colour doppler capabilities and have curvilinear and linear transducers. Every department uses PoCUS for FAST, AAA, ECHO in life support and Central & Peripheral vascular access. Around 50% of the departments utilise PoCUS for foreign body removal, shock assessment and DVT diagnosis while 30-40% use it for regional anaesthesia and hepato-biliary studies.

7 out of the 13 (54%) departments have a dedicated PoCUS lead . While Emergency Medicine Consultants and middle grades/ registrars use the US machine in every department, other specialty clinicians use the same machine in 2 (15%) departments.

Only 4/13 (30%) of departments store the images in Picture Archiving and Communication System (PACS) and the rest of the departments store them in either on the US machine hard drive or as thermal prints. 10/13 (77%) departments record the report directly on patient notes while 4/13 (31%) record them in templates.

 9/13 (70%) of the departments do not have built in “safety net” where 4/13 (30%) of the departments have a safety net where non-signed off operators’ scans are supervised immediately or reviewed on a later date by a Level 1 or 2 accredited operator. Only 3/10 (23% ) of the departments have an audit process in place and only  5/13 (38%) has a written policy/ guideline on governance of use of Point of Care US in ED.

Conclusion

From our survey it is clear that Point of Care Ultrasound is used widely by Emergency physicians in their departments. It also highlights deficiencies and inconsistencies around governance in recording, reporting, safety netting and auditing. We feel this needs to be urgently addressed in order to comply with nationally agreed Radiology Guidelines to ensure the safe use of PoCUS by clinicians. Our Emergency Department has developed a Clinical Governance Policy for Point of Care Ultrasound and are in the process of developing a Trust Point of Care Ultrasound Policy to include all clinicians undertaking Point of Care Ultrasound in their clinical practice.  

Background

It has been recognised that increasing numbers of patients are presenting to Emergency Departments (ED) in mental health crisis, whilst access to specialist psychiatric services in certain areas is limited.  In addition, there is a high need for early recognition of mental health problems and a call for more continuous provision of care.  Collaborative working between emergency department staff and mental health clinicians is essential in providing high quality care for patients presenting with mental distress.  We describe and evaluate an interprofessional mental health simulation-based training (SBT) course for front line staff working in an inner city ED. 

Aims

The primary aim was to improve collaborative working across specialties and professions when caring for patients with mental health difficulties in the ED.

Methods

A half-day interprofessional SBT course was developed in which participants engaged in three scenarios following one simulated patient’s journey through the ED.  A debrief model was used to allow participants to learn positively and constructively from their shared experiences. 

Changes in participants’ attitudes were examined using pre and post self-rating questionnaires.  Statistical analysis was conducted using Wilcoxen Rank Signed Rank Test.  Qualitative data was obtained from follow-up focus groups, which further examined participants’ experience of being in the simulation, and their integration of learning into practice. 

Results

37 individuals of a broad professional mix participated:  security officers, ED nurses, emergency medicine residents, psychiatry residents, and mental health nurses. 

Attitude scores moved in a positive direction significantly for half the items.   Most significant was increased comfort with the participants’ own roles and responsibilities as a member of the multidisciplinary team (p = 0.004) and with those of other team members (p = 0.011) when caring for patients with mental health difficulties.

Thematic analysis of follow-up focus groups revealed that the intervention encouraged reflection on other professions’ perspectives and consideration of colleagues’ particular skills and expectations when working with patients who present in mental health crisis.  Participants reflected on how they would put into practice “joint working” by sharing information and involving other team members from different disciplines earlier.

Conclusions

This study presents evidence that interprofessional SBT is an effective tool in encouraging teams to reflect on factors which impact on effective collaborative working when managing patients presenting in mental health crisis in the ED.  Further work is needed to establish whether this leads to a sustained cultural change across the ED.

Introduction: Inappropriate use of emergency medical services has been discussed for over a decade within mainstream media and medical publications. The majority of epidemiological studies and investigations into this problem have been from the ambulance service, reporting service abusers and 999 calls that do not result in transportation to hospital. This study analyses the patient cohort who have dialled 999 resulting in transportation to hospital, with medical assessment, diagnosis and outcome of the attendance contributing towards the decision of whether the call to emergency service was appropriate or inappropriate.

Method: We conducted a retrospective analysis of all ambulance admissions at a Major Trauma Unit in South Wales. The emergency department notes of all patients arriving by ambulance from January 1^st though March 31^st 2015 were reviewed. Key information regarding presenting complaint, triage disposal, clinical observations, diagnosis, treatments required and outcome of attendance were collated. These contributred toward an overall analysis of appropriate utilisation of the emergency medical services in the local area.

Results: 6600 ambulances attended A&E during the 3 month study period, including 11 air-ambulance retrievals, representing 35.4% of total patient attendances. From this cohort, 2426 patient (36.8%) were either admitted or transferred to another specialist centre. 4174 patients (63.2%) did not require admission, 37.6% were referred back to the general practitioner, 12.5% were discharged with no follow-up necessary, 4.1% were discharged with a follow-up in the emergency department, 4.2% referred to other outpatient health services, and 314 patients (4.8%) discharged themselves against medical advice, or failed to wait for assessment.

Conclusions:

Following medical assessment within the emergency unit, over 60% of patients required minimal or no intervention, and monitoring in the community by the patient or GP services was the most frequent outcome. Additional sources of ambulance utilisation included: over-reactions from minor injuries or ailments, concern from surrounding persons, and immediate perceived difficulties in transport were among reasons for dialling 999. Ease of access in panicked situations resulted in a default cry for help. For some patients, key phrase triggers when other services were sought (e.g. NHS Direct)

Advanced medical facilities and highly trained paramedics continue to be used for alternative purposes opposed to time critical or life threatening emergencies, with ease of access and cultural expectation being significant underlying narratives. Improving the availability and communication links of other alternative services, in addition to the level of training to identify patients who require emergency assessment, could mean the avoidance of a large proportion of emergency unit attendances, with more appropriate use and utilisation of emergency facilities for their intended purpose.

Based on our study we propose a model for a multicenter study and we suggest an update of the EM and general practice training curricula, with emphasis on patients' medical education.