Background: Hemodynamic (HD) phenotyping of patients with acute heart failure (AHF) using cluster analysis may help to define potential targets for specific therapeutic interventions. Blood pressure (BP) and pulse do not accurately identify the underlying HD profiles of acutely ill patients in general. Objectives: To derive distinct clusters of Emergency Department (ED) patients with AHF based on their presenting noninvasive HD measurements and to identify any potential distinguishing clinical characteristics among patients within each cluster. Methods: Presenting, pre-treatment noninvasive HD parameters (n=23) were compiled using the Nexfin device (Bmeye/Edwards LifeSciences) from 127 ED patients with confirmed AHF. Based on these parameters, k-means clustering was performed to identify a set of variables that provided the greatest level of inter-cluster discrimination and intra-cluster cohesion. The parameter k, representing the number of clusters, was identified iteratively by maximizing the ratio of inter (discrimination) and intra cluster error (cohesion), with smaller values of k being preferred. Principal components analysis validates the choice of small k as appropriate for the data. Our final model included 3 groups with clustering based on the following mean parameters: stroke volume index [(SVI), ml/M²], systemic vascular resistance index [(SVRI), dynes/sec/cm/M²] and finger mean arterial pressure [(fMAP), mmHg]. Group comparisons were then performed. Results: Cluster 1 had normal cardiac function and vascular resistance (SVI 38.7 ± 9.7; SVRI 2065.4 ± 305.7; fMAP 66.7 ± 21.2); cluster 2 slightly low cardiac function (SVI 31.0 ± 6.2) with increased vascular tone (SVRI 3109.4 ± 379.3, fMAP 81.0 ± 20.0); and cluster 3 very decreased cardiac function (SVI 22.4 ± 7.5) with markedly elevated vascular resistance (SVRI 4696.8 ± 795.3, fMAP 89.8 ±26.5). All p values for the cluster HD parameters were <0.0001. Presenting diastolic BP differed among the clusters. However the systolic BP and other baseline variables (including age, gender, heart rate, history of coronary artery disease and creatinine, BNP and recent ejection fraction values) were statistically equivalent. Conclusions: Among ED patients with AHF, distinct clusters can be defined based on presenting non-invasively derived HD measures of cardiac function, systemic vascular resistance and finger mean arterial BP. This approach may help identify distinct patient subtypes that would benefit from target-specific treatment, providing granularity that cannot be achieved using more traditional ED variables.

Background: The TRAPID-AMI study was a multicenter international trial evaluating the high sensitivity cardiac troponin (hs-cTnT) assay in a rapid "rule-out" acute myocardial infarction (AMI) strategy in the Emergency Department (ED). We evaluated a modified HEART Score (MHS) using historical features (clinical suspicion), ECG, age and cardiac risk factors and a normal hs-cTnT to identify a low-risk patient population that might not require further observation and/or provocative cardiac testing. Each of the elements of the MHS is assigned a 0,1 or 2 with the composite score ranging from 0-8. Methods: There were 1,282 patienst studied in the ED for possible AMI from 10 European, 2 USA and 1 Australian Centers from August 2011 through June 2013. Patients were enrolled if the onset of their chest pain (or equivalent) was less than 6 hours from presentation and hs-cTnT (99%, 14 pg/L) was measured at baseline, 1,2 and 6 hours later. All patients were followed for 30 day adverse events (AEs) which included death and MI. Patients were considered low risk if they had hs-cTnT less than or equal to 14 pg/L at baseline and 6 hours and had a MHS less than or equal to 3. Results: There were 17% (217/1282) of patients that suffered an AE at 30 days overall: 8 deaths (0.6%) and 215 AMIs (17%). There were 40% of patients (514/1282) with normal hs-cTnT values and a MHS less than or equal to 3. The AE (all AMIs) rate in the patients with a MHS less than or equal to 3 was 0.2% (1/514) amd those with a MNS 4 or greater 1.8% (5/285) (p = 0.024) .Conclusions: Serial testing of hs-cTnT along with application of a MHS may identify a very low risk ED chest pain population that might be able to be directly discharged from the ED without further observation and/or provocative testing with outpatient follow up within 30 days. Further prospective trials are needed to verify these results.

Background. The diagnosis of acute aortic syndromes (AAS) is a challenge for Emergency Physicians due to lack of sensitive and specific signs and symptoms. Patient stratification according to pre-test probability of AAS is suggested to standardize both evaluation and diagnostic decisions on aortic imaging. The Aortic Dissection Detection (ADD) risk score, indicated by the 2010 American Heart Association and 2014 European Society of Cardiology guidelines, can be used to evaluate the pre-test probability of AAS according to the presence/absence of 12 risk factors. Accordingly, three risk categories of patients can be defined: low, medium, and high-risk of AAS. However, the ADD risk score is relatively complex and is not easy to routinely implement in the Emergency Department (ED). Aim of this study was to compare the predictive value of several risk factors for AAS and to develop a simplified score allowing more straightforward risk-stratification for AAS in the ED. 

Methods. Consecutive patients admitted to the ED with a clinical suspicion of AAS were enrolled in two EDs between 2008 and 2013. Patients were included in a registry if the following criteria were satisfied: (1) presence of chest pain, back pain, abdominal pain, syncope or signs/symptoms of perfusion deficit; (2) unclear diagnosis after initial medical evaluation; (3) order of an urgent aortic imaging exam by the attending physician to identify/exclude AAS. Trauma patients were excluded. The final diagnosis was based on computed tomography angiography results. For each patient, we retrospectively reviewed ED charts to calculate both the ADD risk score and a simplified score. Risk factors for the simplified score were identified based on their potential predictability, calculated using the modified Rho2 Spearman’s rank correlation coefficient. We assessed the discriminatory ability of both scores using the c-index.

Results. 1,328 patients with suspected AAS were enrolled in the registry, and 291 (21.9%) had a final diagnosis of AAS. The ADD risk score was 0 (low-risk) in 439 (33.1%) patients, 1 (intermiediate-risk) in 646 (48.6%) patients and >1 (high-risk) in 243 (18.3%) patients. Based on Rho2 coefficient, we identified 5 highly predictive variables for AAS to be used in the simplified score: severe pain, abrupt onset of pain, pulse deficit, hypotension and focal neurologic deficit. Both the ADD risk score and the simplified score had a high c-index (0.73 and 0.72 respectively). Using the 5-variable model, we also built a nomogram for rapid evaluation of AAS risk in the ED. The agreement between expected and predicted scores for the simplified model was assessed by calibration analysis. The performance of the simplified model was similar to that of the ADD risk score, and the simplified score in particular showed a good predictive capacity amongst non-high risk patients.

Conclusion. This is first attempt to simplify a published scoring system for suspected AAS. Our 5-variable simplified risk score showed a discrimination power similar to the 12-variable ADD risk score. External validation of the simplified score is needed, and a new prospective study is currently recruiting.

Background. During a previous study performed in our emergency department (ED), about comparison between electrical and pharmacological cardioversion of paroxysmal Atrial Fibrillation (AF), higher values of hematocrit were observed in patients with AF. A positive correlation between higher hematocrit and incidences of paroxysmal AF have already been reported in a small number of patients and in some studies of the 90s - early 2000s. It is still to be clarified if hemoconcentration itself is the cause of the arrhythmia, or, alternatively, is caused by Atrial Natriuretic Peptide (ANP) hypersecretion during the paroxysms of AF.

Objectives. The aim of our study was to investigate the possible proarrhythmic role, mostly for the AF, of the hemorheological abnormalities due to increased hematocrit.

Materials and methods. Between December 2014 and March 2015, a control case-control study was carried out on patients presenting to the ED complaining of “palpitations”. For all these patients, we asked all physicians of our ED to fill in a form reporting: medical history, medications, vital signs and ultrasound measurement of dynamic changes of inferior cava vein (IVC) diameter.

The patients with paroxysms of AF or supraventricular tachycardia (SVT) were reviewed after a month, in order to complete the same form, perform the ECG, and collect the same blood samples.

Results. We enrolled 167 patients: 98 patients were analyzed, 59 had sinus rhythm and 39 had supraventricular arrythmia (33 AF and 6 SVT); 69 patients were excluded. Incidence of recent profuse sweating (p=0.085) and polyuria (p=0.083), and assumption of antiarrhythmic agents (p=0.0003) or drugs that induce a decrease of hematocrit (p=0.015) were higher in patients with arrythmia. Mean + standard deviation values of hemoglobin (Hb) [151.20+12.55 vs 141.42+13.23 g/L (p=0.0004)], red blood cells (RBC) [8.29+1.97 vs 7.34+2.40 x10.12/L (p=0.01)] and white blood cell count (WBC) [5.14+0.46 vs 4.88+0.57 x10.9/L (p=0.01)], hematocrit (HCT) [0.465+0.034 vs 0.433+0.039 (p<0.0001)], urea [6.34+2.32 vs 5.22+1.55 mmol/L (p=0.003)], creatinine [88.71+21.53 vs 79.10+5.99 umol/L (p=0.007)], sodium [140.48+1.81 vs 139.72+1.73 mmol/L (p=0.04)], osmolality [292.05+4.48 vs 285.88+5.14 mOsm/Kg (p<0.0001)], Prohormone Brain Natriuretic Peptide (NT-proBNP) [604.56+1143.45 vs 87.45+160.41 ng/L (p<0.0001)] and Erythropoietin (EPO) [13.11+7.36 vs 10.53+5.51 IU/L (p=0.015)], were higher among patients with arrhythmia. No difference was found between the two groups regarding platelets count, MCV, calcium, magnesium, TSH levels, blood pressure values and IVC diameter changes.

After 1 month, patients with arrythmia showed lower values of WBC (p<0.0001), RBC (p<0.0001), Hb (p<0.0001), HCT (p<0.0001) urea (p=0.02), creatinine (p=0.002), osmolality (p<0.0001) and NT-pro BNP (p=0.0009), while EPO slightly decreased (p=0.036) and IVC values did not change.

No difference were found between the lab values of the group with sinus rhythm and with supraventricular arrhythmias after 1 month, except lower values in calcium, potassium, osmolality, TSH and NT-proBNP.

Conclusion. Our study shows that hemoconcentration is common in patients presenting with paroxysms of supraventricular arrhythmias. These patients shows chronically higher EPO and NT-proBNP values. The hemorheological abnormalities in combination with fluid loss, apparently only in part induced by BNP hypersecretion on an atrium already mechanically stressed, can promote the occurrence of arrhythmias.

Introduction                 

The use of invasive therapeutic treatments is still controversial and under debate for selective elderly patients presenting with  UA/NSTEMI. Age and several comorbidities lead to a difficult management of this kind of patients.

Objectives

Elderly patients are often underrepresented in clinical trials. The aim of this study is to analyze the treatment protocol, the mortality risk factors, the one-year mortality rate and the recurrence rate of MI in elderly patients presenting with  UA/NSTEMI and treated in our Unit.

Methods

This is a review of case study. From  2013 to  2014, 137 patients have been  admitted in the Department of Medicina Interna Area Critica of Policlinico in Modena for the management of acute myocardial infarction. For each patient we analyzed clinical presentation, past medical history (focusing on previous cardiac diseases, renal failure, advance tumour), therapeutic approach and outcomes (one year mortality, recurrence of myocardial infarction). We proceded with a univariated and multivariated analysis of the mortality risk factors and of the one-year overall survival, assessed with Cox regression analysis.

Results

The mean age was 84.2 ± 10.3 y.o. The therapeutic approach was conservative in 117 patients (85%) and invasive (PCI) in 20 patients (15%). The average follow up was 292 days. The overall mortality rate was 43.1% (59 patients). 21 of them (3.6%) died during hospitalization: they were considered “critical patients” since admission.
The population was divided in two groups: patients dead at the time of the analysis and patients still alive. We compared the two groups considering all the data collected. Concerning the survival, the univariated analysis pointed out as prognostic factors: age (p=0.001), urea (p=0.001), creatinine (p=0.003), glycemic decompensation (p=0.029), troponine risen (p=0.048), symptomatic heart failure (p=0.048), conservative approach indication (p=0.020), acute administration of Ace-inhibitors/Sartans (p=0.004), Statins (p=0.004), B-blockers (p=0.012) e Aspirin (p=0.039).
The multivariated analysis showed as independent mortality risk factors: age (Hazard Ratio 1.055, Confidence Interval at 95% 1.014-1.098, p=0.009), troponine risen (HR 1.026, CI95% 1.011-1.043, p=0.001), urea (HR 1.012, CI 95% 1.004-1.020, p=0.004), symptomatic heart failure (HR 1.76, CI 95% 1.01-3.06, p=0.046), glycemic decompensation (HR 1.004, CI 95% 1-1.007, p=0.054), acute administration of Statins (HR 0.43, CI 95%, p=0.015) and Aspirin (HR 0.43, CI 95% 0.22-0.85, p=0.015).

Conclusions

Elderly patients with MI are high mortality risk patients.
One-year mortality is higher in patients conservatively treated, compared to those receiving reperfusion therapies.  The mortality is higher in patients presenting with risen troponine, renal failure, heart failure and glycemic decompensation.
In patients not suitable for invasive treatments, acute administration of selected medications (Aspirin, Statin, Ace-inhibitor/Sartan and B-blocker) is the therapeutic approach to reduce mortality risk at one year

Background: Atrial fibrillation (AF) is the most frequently arrhythmia represented in Emergency department (ED). The risk of thromboembolic events is five times higher in patients with AF than those in sinus rhythm. The vitamin K antagonists (VKAs) are currently the most effective therapeutic class for the prevention of these events.

Objectives: To study the epidemiology of non-valvular AF (NVAF) in ED, assess VKAs prescription in eligible patients and to determine criteria associated with an under-prescription of this therapy.

Methods: Prospective, observational, over two years study. Inclusion criteria: age> 18 years, patients with NVAF eligible for anticoagulation. Non-inclusion criteria: AF treated by VKAs, contra-indications to VKAs. Collection of epidemiological and clinical parameters, classification of NVAF, calculation of ischemic risk (CHADS₂ [Congestive heart failure (CHF), Hypertension (HTA), Age75 years, Diabetes(D), Stroke (S)] or CHA₂DS₂-VASc [CHF, HTA, Age75 years, DM, Stroke, Vascular disease, Age 65 -74 years, Sex category] and bleeding risk (HAS-BLED [HTA ,Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly]) scores. Patients divided into two groups:  VKAs+ Group: patients received VKAs and VKAs- Group. An analytic study was done in order to know the parameters significantly and independently associated with under prescription of the VKAs.

Results: During study, 176 patients were enrolled. Mean age: 67±13 years. Sex-ratio=0.5. Cardiovascular comorbidities were present in 68% cases. FA classification: paroxysmal n=114, permanent n=47 and persistent n=15. The mean CHADS₂ score was 1.5 ± 1.2, the mean CHA₂DS₂VASc score was 2.88 ± 1.55 and the mean HASBLED score was 1.52 ± 1.05. VKA prescription rate was 36%. In multivariate analysis, age >70 years (OR=1.59, 95%CI[1.11-2,21];p<0.001), creatinine level ≥110 µmol/l(OR=2,54;95%CI[1,20–5,37];p=0,01) and aspirine use (OR =1,7;95%CI[1,08-2,67];p=0,02) were independently associated with non-prescription VKAs. The main causes of VKAs underuse reported by the emergency physicians were: factors related to patient characteristics n=38, factors related to emergency physician n=62, factors related to the patient environment n=20 and factors related to the drug n=22.

Conclusions:  The prescription rate of VKAs was 36%. To optimize this rate, the prescription of VKAs must be in a socio-medical perspective taking account the socio-economic conditions of each patient. The goal is to aim for appropriate and rational management to improve the prognosis of this disease.

Background:  Clinical and laboratory characteristics of individuals presenting to the emergency department (ED) with hypertensive urgency (HU) are not well characterized. 

Methods:  In a retrospective chart review study, 150 consecutive patients admitted to a tertiary care center ED with HU (systolic blood pressure values >180 mmHg or diastolic blood pressure values > 110 mmHg without evidence of end organ involvement) were compared with 150 patients with normal blood pressure evaluated in the surgical ward of the same emergency room.  Demographic variables, co-morbidities and laboratory values were compared between the two groups. 

Results: HU patients were older (66±16.1 years vs. 61.7±19 years, p=0.04), had a greater prevalence of hypertension 90% vs. 64%, p=0.001), were treated with more anti-hypertensive medications (1.9±1.4 vs. 1±1.3, p=0.001) and had a higher prevalence of chronic kidney disease (10.6% vs. 4% p=0.044). Laboratory findings were similar in HU and normotensive individuals.

Conclusions:  HU in an ED setting is more prevalent among elderly, hypertensive individuals, particularly among those with chronic kidney disease  

BACKGROUND

Patient safety is an topic of particular concern in pediatrics. Developing a risk map in a Pediatric Emergency Department (PED) using proactive strategies (PS) and reactive strategies (RS) can help to identify risks and promote an improvement of health quality. However, to the best of our knowledge, no risk map has been developed in the Emergency setting combining these two strategies.

OBJECTIVE

To develop a risk map in a PED of a tertiary teaching hospital combining PS and RS.

METHODS

PS: After several meetings, a document identifying several risks was written and reviewed by external consultants.

RS: the incidents reported by professionals and caregivers of the children admitted in the PED from Nov´04-Dec´13 were analyzed.

Results obtained from both strategies were classified using the International Classification for Patient Safety from the World Health Organization and the degree of the risks was classified according to the official classification system of the Spanish Ministry of Health.

Finally, the map was created combining both strategies.

RESULTS

PS: 49 failures, 60 effects and 252 causes were identified. Most common failures were related with the discharge of the patient (mainly identification of the patient and delay of the process). Most common effects were related with complaints of the caregivers, prolonged length of stay in the PED, delay in diagnosis/treatment and unnecessary treatment. Most frequent causes were due to: not including the family in the process, shift change, incorrect identification of the patient and computer error.

RS: 1795 incidents were notified by nurses (33%), caregivers (25%), PED pediatricians (14%), director of the ED (13%), quality manager (9%) and others (6%). Most of them were related with medical equipment (38%), resources/organization of staff (17%), clinical process (15%), facilities (12%) and medication errors (5%).

PS identified risks in several phases of the clinical process: complementary tests, treatment and discharge. RS added risks about prehospitalary transportation, triage, medical care, complementary tests, treatment and discharge.

CONCLUSSION

The combination of PS and RS improves the quality of the risk map in a PED. The involvement of different professionals and caregivers enables the risk map to accurately reflect the real situation of the PED.

Background: Pain is a physical and psychological negative experience, often linked to suffering. It is therefore important to alleviate it as soon as possible using the most appropriate and pleasant medication for the patient.

Objective: To test the non-inferiority in terms of efficacy of buccal paracetamolvs syrup or tablet paracetamol in reducing pain in pediatric patients referred to the Emergency Department for headache, earache, nonspecific abdominal pain (NSAP).

Materials and Methods: we conducted a non-inferiority monocentric retrospective observational studyon children between 3 and 14 years, in which pain was assessed by Wong-Baker scale at entrance and 60 minutes after administration of analgesic therapy in triage. The data were collected using special data collection and processed by statistical analysis.

Results: We analyzed 200 patients (70 buccal vs 130 tablet or syrup), with mean entrance pain level of 4.77/10. Buccal paracetamol was found to be more effective to reduce pain (mean reduction: 2.37/10) vs tablet or syrup paracetamol(mean reduction: 1.95/10) (p<0.05), in particular for earache (2.32/10 vs 1.90/10, p<0.05) and NSAP (2.43/10 vs 1.93/10, p<0.05). In addition, there were statistically significant differences (p<0.05) depending on the intensity of pain, age, gender and nationality.

Conclusions: Buccal paracetamol was found to be more effective in reducing pain in certain conditions. It is therefore a specific pediatric nurse task to take into account the peculiarities of each patient in administration of paracetamol. Further similar studies are desirable on other painkillers.

Background

Community acquired Pneumonia (CAP) is the most frequent serious infection among children with fever. The rate of antibiotic prescribing amongst children suspected of CAP is high, contributing to antibiotic resistance in the community. Diagnostic tools for guiding antibiotic prescribing in children with fever are needed.

Aim: To evaluate the diagnostic value of the Feverkidstool, a  validated decision rule using clinical features and CRP,  to safely identify children suspected of CAP who do not need antibiotics.

Methods

Patients: previously healthy children aged 1 – 60 months, with fever and cough  at risk of CAP, visiting the emergency department of ErasmusMC in 2013.

Outcome: children suspected of CAP recovering without antibiotics.

Prospective observational study with standardised data collection. Risk of CAP was calculated using the Feverkidstool, a validated prediction model for febrile children (www.erasmusmc.nl/feverkidstool).

Results:

In a population of 248 children (median age 14 mo (IQR 7-27), 51 children received  antibiotic treatment (21%), of whom 53% received amoxicillin; 55 (22%) were hospitalized. For both the frequency of antibiotic prescription and the predicted risk for CAP by the Feverkidstool, we observed a high association with the doctors decision to perform chest radiographs, but not for the result of the chest radiograph. The risk for CAP predicted by the Feverkidstool was significantly associated with increased antibiotic prescription, even after correcting for age, gender and performing a chest radiograph. The discriminative value of the Feverkidstool was 0.67 (0.60-0.74)  to identify children suspected of CAP not needing antibiotics. In a population with low antibiotic prescription rate, the Feverkidstool cutoff of 10% had specificity of 73% to correct identify children suspected of CAP not needing antibiotics; specificity increased to 89% using a 20% cutoff.  In children with predicted risks below these thresholds, a follow-up strategy to detect deterioration and to start delayed antibiotic treatment if necessary, was safe.

Conclusion:

The Feverkidstool safely identifies children suspected of CAP who do not need antibiotics. This adds to reducing unnecessary antibiotic prescription in febrile children. 

Background

Urinary tract infection (UTI) is the most common serious bacterial infection (SBI) in febrile infants. A primary diagnosis can be made in the emergency department if an altered urine dipstick test is obtained. Spanish guidelines recommend inpatient treatment in patients less than 90 days old with UTI suspected.

Objective

To describe the management of febrile young infants with in a urine disptick and analyze factors associated with an outpatient management.

Patients and methods

Subanalysis of a prospective multicentric study developed in 19 Spanish Pediatric Emergency Departments (PED) included in the Spanish Pediatric Emergency Research Network (RISEUP-SPERG), including febrile infants less or equal than 90 days old with fever without source (FWS) attended at the PED between October-2011 and September-2013.

An urine dipstick was considered altered whien either a leukocyte esterase test or nitrite test were positive.

Results

A total of 3,401 infants were included. Of them, 765 (22.5%) had an altered urine dipstick and 72 (9.4%) were managed as outpatient, 30 after an observation period shorter than 24 hours. After a multivariate analysis, variables that remained as independent factors for an outpatient management were: being well-appearing, being older than 60 days old and presenting a C-reactive protein (CRP) less than 20 mg/L and a procalcitonin (PCT) less than 0.5 ng/mL.

Among the 72 patients managed as outpatients, 51 received antibiotic treatment (70.8%; via oral in 27 and parenteral in 24). Overall, urine culture grew >50,000 cfu/ml in 36 (50%) of them, and 10000-50000 cfu/ml in other 3 (4.2%). None of them was admitted after receiving the results of the urine culture. Two patients had bacteremia, both of them received one dose of parenteral antibiotic in the emergency department prior to discharge. Both patients were afebrile when blood culture result was received.

Conclusions

A significant proportion of febrile young infants with a suspected UTI are managed as outpatients. Well appearing patients older than 60 days old with normal CRP and PCT values are more frequently managed as outpatients.

Bone and joint infections present a major diagnostic challenge in the paediatric emergency department (PED). The presenting features of osteomyelitis and septic arthritis in children can vary greatly and can be difficult to distinguish from other conditions.

Method

We performed a retrospective review of the medical notes and electronic patient records of children diagnosed with osteoarticular infections over a 12-year period at a Paediatric Emergency Department (PED) serving a diverse urban population. We compared the presenting features and investigations to the literature and current trends in practice.

Results

A total of 88 cases of osteomyelitis and/or septic arthritis presented to the PED and were managed at the same hospital during the study period. Fever, pain, impaired function and localised changes were commonly reported at presentation but overall there was inconsistency in the incidence of these features among patients with osteoarticular infections.

Inflammatory makers were sensitive tools in identifying bone and joint infections, particularly when used in combination. When CRP, total white cell count and ESR were all abnormal, 98% of bone and joint infections were identified.

A positive microbiological diagnosis was only obtained in 38% of cases, the largest proportion being from cultures of synovial fluid and bone tissue. Streptococcal organisms were significantly more likely to be isolated in children under 5 years than in children over 5 years (p = <0.001). Conversely staphylococcal organisms were significantly more likely to be isolated in children over 5 years than in children under 5 years (p = <0.001).

It is of concern that virulent organisms such as PVL staphylococcus aureus and MRSA were identified in some of our cases. This should prompt review of antibiotic choices and broaden diagnostic techniques.

Overall, children under 5 years of age were significantly more likely to be diagnosed with septic arthritis than osteomyelitis (p = 0.006). Children over 12 years of age were significantly more likely to be diagnosed with osteomyelitis than septic arthritis (p = 0.019).

Conclusion

Our experience highlights the difficulty of differentiating osteoarticular infections from other conditions using clinical features alone. Diagnosis of bone and joint infections requires a combination of clinical suspicion and investigations. However, the differences we identified between the incidence of osteomyelitis and septic arthritis and the variation of causative organisms across age groups may be useful to consider at presentation and in cases of diagnostic uncertainty.

Introduction

The practice of family centred care within paediatric hospitals has continuously evolved over the past number of decades, with parents now considered essential participants in their child’s care. Parents are now routinely present during situations where they previously would have been asked to leave e.g. intravenous cannulation, lumbar puncture and cardiopulmonary resuscitation (CPR). However controversy remains around the presence of parents in the paediatric resuscitation room. There is a paucity of evidence to support the practice, few policies/guidelines and few established programmes which provide specific training.

Outcome Measures

The primary outcome measure was to identify healthcare professionals’ attitudes towards parental presence in the resuscitation room during paediatric resuscitation. Secondary outcome measures included:

1. Identification of barriers towards parental presence during paediatric resuscitation

2. Identification of methods to facilitate parental presence

3. Identification of methods of training suitable for clinicians involved

Methods

An anonymous questionnaire was created and distributed among healthcare professionals involved in paediatric resuscitation. The purpose of the audit was to gain perspective into the thoughts of the healthcare professionals involved in paediatric CPR and discover their views on what the best methods of training in dealing with parental presence are.

Results

There were 36 respondents to the questionnaire: 24 doctors and 12 nurses. Of the doctors, 12 were emergency physicians, 10 were paediatricians and 2 were anaesthetists. The majority of respondents (n=22, 61%) stated they were happy for parents to remain during a procedure/resuscitation. The majority of respondents (n=26, 72%) felt that parents/family members should be present in the resuscitation room during the resuscitation process. However they did not feel that they had adequate training in how to deal with family members during paediatric resuscitation (n=32, 89%). The majority of participants did not agree that their training had prepared them for any difficulties that could arise with having parents/family members present in the room during a resuscitation (n=29, 81%). Respondents were asked if their APLS or NRP training had dealt with the situation where relatives are present in the room during paediatric resuscitation. Of the 27 participants who were eligible to answer this question, the majority did not agree (n=19, 70%). All of the respondents said that they would welcome additional training in running a resuscitation with relatives present.

When asked to rank types of training a lecture followed by simulation of distressed relatives was the most popular method with 22 (61%) participants ranking it highest. The second most popular was training with simulation alone (n=14, 39%). No other method of training was given a highest ranking. The least popular method of training was a booklet with 26 respondents (72%) ranking it lowest. It was followed by computer/e-learning with 6 participants (17%) ranking it lowest.

Conclusions

Parental presence during paediatric resuscitation is increasing and guidelines should be developed to facilitate it. This small audit demonstrates that clinicians welcome relatives being present, but would welcome education in on how to facilitate parental presence during paediatric resuscitation. Simulated scenarios together wih formal instruction would be the preferred ecucation methods.

Background:

High-flow oxygen (HFO) therapy has been shown to be efficacious and safe treatment in pediatric populations with acute respiratory processes. There are, however a lack of studies about its application in the ED.

Objective:

The aim of our study is to assess the feasibility of HFO treatment and assess its efficacy and safety given to children with asthma and moderate respiratory failure attended in the emergency department (ED).

Patients and method:

This was a prospective randomized trial of children (1 – 16 years) who presented to the ED with acute asthma. Patients with a Pulmonary Score (PS) ³ 6 or oxygen saturation < 90% with FiO2 40, despite initial treatment with nebulized salbutamol every 20 minutes during the first hour (at least 3 doses) were randomly assigned to one of two treatment groups. The experimental group received HFO therapy and the control group conventional oxygen therapy. Along with oxygen therapy the pharmacological treatment of acute asthma was left to the discretion of the attending physician.   

The PS, oxygen saturation, respiratory rate and heart rate were recorded at 30 minutes, 1 hour 2 hours and then every 2 hours after initiation of therapy.

At the end of the study a satisfaction questionnaire was distributed among the PED staff.

Results: Duringa period of 24 months (Oct 2012 – Oct 2014), 52 patients met the inclusion criteria and 36 patients were studied (18 in each study group). Characteristics of patients at baseline did not showed differences except in the mean PS that was higher in HFO group (6.5 (1.29) in the HFO group vs. 6.05 (0.23) in control group; p<0.001). At two hours after initiation of therapy Pulmonary Score decreased more than 2 points in 11 patients (61.1%) in HFO group vs. 5 (27.8%) in control group (mean PS scores 4.77 (1.16) and 5.05 (1.05) respectively); p<0.05). No differences were found in oxygen saturation mean values at this time, 95.77 (1.76) and 97.81 (2.04) respectively. Eleven patients (51.1%) in HFO group were finally admitted in ward versus 7 (38.9%) in control group. The satisfaction questionnaire was answered by 42 professionals and 36 (85%) considered HFO treatment as a positive experience. No adverse effects were reported.   

Conclusions: HFO treatment is feasible and safe when given in the ED. HFO improves the overall respiratory status of children with acute asthma and moderate respiratory failure. Further studies are needed to prove its overall effectiveness in the management of patients with asthma and respiratory failure in the emergency department.

BACKGROUND: Real-time ultrasound guidance has demonstrated to improve the success and to reduce the incidence of adverse events during medical procedures. Ultrasound-guidance during thoracentesis has decreased the likelihood of pneumothorax by 19% --thereby improving the overall outcomes. Since the needle orientation in a longitudinal axis provides better precision and decreases the rate of adverse events during ultrasound-guided vascular access, we hypothesized that ultrasound-guided thoracentesis performed with a longitudinal axis approach could also have better outcomes. To our knowledge, this technique and its potential benefits have not been yet reported in the literature. We aimed to describe the real-time ultrasound-guided thoracentesis using longitudinal axis approach.

OBJECTIVE: To describe the outcomes of ultrasound-guided thoracentesis using a longitudinal axis approach in an Emergency Department in Bogotá-Colombia.

METHODOLOGY: We described two different techniques of ultrasound-guided thoracentesis: 1) the conventional (out of plane) and 2) the longitudinal axis (in-plane), in the Emergency Department of Fundación Cardioinfantil - Instituto de Cardiología, from October 1, 2013 to September 10, 2014. The measured variables were: difference between pleural effusion depth at the puncture site, success rate in pleural fluid removal, and adverse events.

RESULTS:  We performed 47 ultrasound-guided thoracentesis using the conventional approach and 26 ultrasound-guided thoracentesis using the longitudinal axis approach. Pleural effusion depth median  at the puncture site was 32.5 mm in the longitudinal axis group, compared to 47 mm in the conventional technique group (p = 0.0225), with a lowest pleural effusion depth of 15 mm and 20 mm respectively. Success rate in fluid removal was 100% in thoracentesis performed with longitudinal axis approach, compared to 93% (44 out of 47 procedures) with the conventional approach. One pneumothorax occurred in the conventional technique group. Thoracentesis was performed in the first attempt in all cases when longitudinal axis was used. Six thoracentesis required more than one attempt of puncture in the conventional technique group.

CONCLUSION: Longitudinal axis approach during ultrasound-guided thoracentesis is a feasible and safe technique that could potentially improve the success rate in pleural fluid removal while reducing the likelihood of adverse events. Additional clinical studies are needed to support our findings.

INTRODUCTION:

Deep venous thrombosis (DVT) is an increasing major cause of mortality and morbidity. There is a need for quick, easy, inexpensive, convenient, and reliable diagnostic tools.

OBJECTIVES:

To ascertain the diagnostic concordance of emergency doctor-performed ultrasound (EDUS) of the lower extremities with specialist doctor-performed echo doppler (SDED) in the diagnosis of DVT.

METHODS:

In this prospective, multicenter study, adult patients (>18 years old) with clinical suspicion of DVT, with high or moderate risk (on Wells scoring) or low risk with increased D-dimer levels, were eligible.

From September 2013 to September 2014, 328 patients were enrolled. Fifty-one investigators from seven hospitals performed the EDUS. Each patient had the EDUS and SDED both in femoral and popliteal areas.

The final result was considered non-concordant if one or both of the EDUS did not match with the SDED. For inter-rater agreement analysis, we used the Kappa statistic,¹² and confidence intervals (CIs) of 95% were computed using a jack-knife re-sampling procedure.

RESULTS:

Of 328 pairs of US studies, 37 were non-concordant between EDUS and SDED. Two EDUS were incomplete; therefore, the concordance analysis was performed with 326 ultrasound studies, with 35 discordant.

The percentage of agreement between EDUS and SDED was 89%. The kappa index was 0.76 (95% CI = 0.69–0.84), which means a “substantial agreement.”

CONCLUSIONS:

There is substantial agreement between the EDUS and SDED in the diagnosis of DVT in routine clinical practice.

WHAT THIS STUDY ADDS:

What is already known on this subject

           Current available evidence suggest that emergency doctors can perform bedside ultrasonography to diagnose or to rule out DVT, in a quick, inexpensive, and accurate way in comparison with “gold standard” studies by the Radiology department.

           Nonetheless, important concerns have been raised about the interpretation of the data: small sample sizes and methodological issues (very different experience of the emergency doctors performing bedside ultrasound, lack of details involving patient enrollment)

Section 2: What this study adds

           There is a “substantial agreement” between bedside ultrasound performed by a homogeneous sample of novice in bedside ultrasound management emergency doctors, and Doppler ultrasound performed by the Registrar radiologist in the diagnosis of DVT of lower limbs.

           The diagnostic concordance will escalate from 89% to 95% if the emergency doctor is shadowed in the first five performances, when the most mistakes are made.

Background/Introduction

Head injury is a common paediatric Emergency Department presentation¹. The National Institute for Health and Clinical Excellence (NICE) updated its guidance in January 2014 regarding imaging required for adults and children following a head injury¹. This study looked at compliance rates pre-guideline and post-guideline implementation.

Participants and methods

A single-centre, retrospective cohort study was carried out, examining imaging practice in children with head injuries pre-guideline and post-guideline implementation. Extraction was from patients’ records and radiology department imaging registers. The new guidelines were implemented formally in August 2014 to the new trainee doctors. The pre-implementation data collection consisted of a 2-month period between and including November 2013 to December 2013 and the post-implementation stage consisted of 2-month period between and including September 2014 to October 2014. The primary outcome measured was compliance with the 2014 NICE guidelines. As the data was binary, 95% confidence intervals were used for comparison.

Results

1797 patients were identified as having a head injury, of which 62.7% were male. There was a positive skew of ages with a median of 50 months. Pre-guideline implementation, 4.8% (95% CI 3.3% and 6.2%) had a CT head scan performed. Post-guideline implementation, there was a reduction to 2.4% (95% CI 1.4% and 3.4%). Implementation at The Sheffield’s Children NHS Foundation Trust (SCFT) resulted in a statistically significant increase in guideline compliance from 79.2% (95% CI 76.4% and 81.9%) to 85.0% (95% CI 82.8% and 87.3%). The greatest increase in compliance was found in CT head scans, from 95.8% (95% CI 94.5% and 97.2%) to 97.7% (95% CI 96.7% and 98.6%). The compliance for CT C-spine scanning was hard to assess due to few patients having clinical indications for this.

Discussion/Conclusion

The implementation at the SCFT was successful in satisfying the aim of the NICE Head Injury 2014 guidelines by increasing compliance and decreasing CT head scans¹. The increase in compliance is contrary to previous studies, indicating a former reluctance to adhere to NICE guidelines for imaging children².

References

1. National Institute for health and care excellence. Head Injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. Methods, evidence and recommendations. CG176. 2014.
2. Mooney JS, Yates A, Sellar L, Shipway T, Roberts C, Parris R, et al. Emergency head injury imaging: implementing NICE 2007 in a tertiary neurosciences centre and a busy district general hospital. Emergency medicine journal. 2011;28(9):778-82.

Acknowledgements

Thank you to the Sheffield Children’s Foundation Trust for data access. 

Introduction

The ultrasound-guided management in pre-hospital emergency medicine has come out as an emerging subject of clinical research and publication over the last decade. But it does not seem to have become common practice amongst SMUR (mobile intensive care units) yet [1]. Nonetheless it remains a tool that has proven its efficiency for diagnostic certitude improvement [2] and that could also modify pre-hospital medical management [3].

The use of a compact, light, hand-held ultrasound device with an optimized ergonomy such as the V-Scan ® seems to be the best option in our practice.

Prospective studies are lacking. We wish to assess the influence of the use of echoscopy in the pre-hospital setting: diagnostic certitude, length of intervention, patient’s treatment and orientation.

Material and methods

• Prospective mono-centric interventional pilot study in current care setting.
• Inclusion criteria: any patient over 18 years old, that are managed in the pre-hospital setting, for one targeted motive amongst a few (related to  traumatology, haemodynamic failures, cardio-respiratory distress…).
• Medical management is completed with a VScan® echoscopy, according to a procedural sequence. Non-experienced physicians are given a 16-hour training in emergency ultrasound examination before participating to the study.
• We mainly assess modifications of orientation that are attributable to echoscopy. Secondary judgement criteria are: modifications of diagnosis, diagnostic certitude before and after echoscopy (according to a numeric auto-assessment on a scale from 0 to 10), therapeutic changes that are attributable to echoscopy, and stratification of those results according to the doctor’s experience (experienced versus minimal training).

Results

• 114 patients are included over 8 months by 14 physicians: 8 junior doctors who received the minimal training (60% of investigated patients), and 6 doctors who are experienced (specific training and qualification in ultrasound scan with over 3 years of experience). Main motives of intervention are chest pain (54%), shortness of breath (15%), or severe traumatology (10%).
• The mean duration of echoscopy is 5.7 minutes and is not influenced by the experience of the investigator.
• A change of orientation occurs in 17% (CI95%; 11-25%), with a trend toward superiority of experienced doctors (23 versus 13%; no significant difference).
• After echoscopy, main diagnostic hypothesis does change in 21% of cases, and therapeutic management in 15%.
• Diagnostic certitude is mostly increased when it is initially scored between 3 and 7 over 10.

Discussion:

This pilot study already shows the usefulness of ultrasound examination with an ultraportable device in the pre-hospital setting. It seems to have an influence on orientation decision and therapeutic management. This improvement does not have a significant duration cost. A targeted training over 2 days is enough to show positive results, and advanced training improves even more those results. A minimal training should particularly target focused echocardiography skills. A study on a larger scale is currently being conducted.

References:

[1] Ann  Fr Anesth Reanim. 2014 ; 33(3):29-33

[2] Am J Em Med 2006; 24, 237–242

[3] Congrès Urgences 2012; CP 158

INTRODUCTION: Acute mesenteric ischemia (AMI) is considered a vascular emergency and mortality is time dependent. Early diagnose is challenging as presenting symptoms are non-specific. The aim of this study was to evaluate the performance of duplex ultrasound (DUS) of the splanchnic vessels to detect AMI against the reference standard of multi-detector computer tomography (MDCT) abdomen scan  in patients presenting to the Emergency Department with abdominal pain and no clear diagnosis after early standard assessment.METHODS: This observational prospective study was performed in two hospitals between October 2012 and April 2014. All patients underwent to MDCT of the abdomen using arterial, venous and portal acquisition. A single operator recruited and performed the DUS blind to MDCT reports. Inclusion criteria were: age >18; acute abdominal pain with onset <24h and/or altered bowel habit; history of atrial fibrillation and/or atherosclerosis in any vascular territory; no diagnosis after standard tests. Duplex assessment was performed of the coeliac arthery (CA) and superior mesenteric artery (SMA) taking a sample of the peak systolic velocity (PSV). We considered normal PSV values between 90-190 cm/sec for the CA and between 80-200 cm/sec for the SMA. Statistical analysis was performed using Student t test, χ2 test, Fisher exact test, whenever appropriate, to assess differences among AMI and non-AMI groups.RESULTS:49 patients were eligible for the study: two withdrew consent and DUS not feasible in two patients leaving 45 for analysis, among this MDCT diagnosed 15 AMI cases. DUS revealed a median SMA PSV of 276.3cm/sec (SD:149,6) and of 188,3 (SD:140,5) in AMI and non-AMI groups respectively (p=0.01). The median CA PSV values were 241,7cm/sec (SD:191,5) and 196,7cm/sec (SD:155,3) in AMI and non-AMI groups respectively (p>0,05). Considering both SMA and CA, abnormal PVS values were found in 27 patients, 12 of them had AMI. Of the remaining 18 patients with normal values, just three had AMI.  PSV reached a 80% (95%CI:51.91-95.43) sensitivity, 50% (95% CI: 31.31-68.69) specificity, 44,44%(95%CI: 25.50-64.66) PPV, 83,33%(95%CI: 58.56-96.23) NPV.CONCLUSION:The investigator achieved PSV readings of the SMA in 45/47 (96%) and of the CA in 44/47 (94%) of patients. A normal PSV has a high NPV for AMI (83,33%) suggesting the diagnosis is unlikely. However the PPV of an abnormal PSV is 44% and so suggests but does not confirm the diagnosis. MDCT angiography remains the gold standard for the diagnosis of AMI, although DUS PSV values could be a feasible and reliable tool that can reasonably rule it out in high risk population. REFERENCES: 1)AbuRahma AF et al. Mesenteric/celiac duplex ultrasound interpretation criteria revisited, J Vasc Surg 2012; 55(2): 428–436; 2)Reginelli EA Genovese EA,et al. Intestinal Ischemia: US-CT findings correlations, Critical Ultrasound Journal 2013; 5(1):S7. Acknowledgements: No funding or conflict of interest. 

Introduction: Videocapillaroscopy (VCS) is a non-invasive diagnostic tool used to assess structure and haemodynamic of microcirculation. VCS is an important tool in the diagnostic management of rheumatologic diseases, but nowadays this technique is also being used in critical care to evaluate microcirculatory changes in sick patients: the rationale beyond this idea is that the primum movens of a number of diseases could be found in microcirculation and studying its alterations could identify early signs and this could help to prevent the progression of the disease. For example, macrocirculatory alterations in sepsis are tardive and often related with a poor prognosis: having the chance to find early signs of microcirculatory failure could help to identify those patients at risk for a worse outcome.

Scope of the study: primary endpoint was to assess quantitative and qualitative microcirculatory alterations in septic patients in the Emergency Department; secondary endpoint was to assess correlations between videocapillaroscopic quantitative parameters and laboratory tests (CRP, lactates, procalcitonin).

Materials and methods: we enrolled 26 non consecutive patients (80  ± 12 years old) with positive SIRS criteria + clinical suspicion of sepsis while 30 healthy individuals were enrolled in the control group. As per our standard diagnostic workup, all patients underwent vital signs evaluation (heart rate, blood pressure, respiratory rate, body temperature) and blood samples were taken for lab tests (procalcitonin, c reactive protein, lactates, blood gas analysis, full blood count, u&e, mioglobin and ck). All the enrolled patients were assessed with VCS by an expert indipendent operator: periungual bed and bulbar conjunctiva were the anatomical sites chosen for videocapillaroscopic evaluation. All the images were recorded and analyzed for qualitative (flow velocity, hyperemia, background paleness, loop orientation, wall abnormalities, tortuosity, transparency, visibility, capillary distrophy) and quantitative (lenght and diameter of the afferent, middle and efferent loop) parameters. The final diagnosis was made by the emergency physician after the full work up and compared with capillaroscopic findings.

Results: septic patients had significative qualitative and quantitative alterations if compared to healthy subjects (ANOVA with Bonferroni post-hoc test). Statistical signifitivity was found for flow alterations, hyperemia, background paleness, loop orientation, wall abnormalities, tortuosity, trasparency, visibility and capillary distrophy; also, we found that middle loop is stretched in septic patients if compared with controls. To assess the secondary endpoint we used Pearson's score to correlate quantitative parameters to procalcitonin, c reactive protein and lactates: we found that the lenght of the afferent and efferent loop were related to all these three parameters. 

Conclusions: VCS is a reliable tool for an early diagnosis of sepsis and its use in an Emergency Department is feasible. This is still a preliminary study and the enrollment is still ongoing to increase the statistical power of the study. A further step will be made comparing clinical scoring systems with serial VCS recordings to assess prognostic value of this methodic.

Ultrasound guided chest compressions during cardiopulmonary resuscitation (CPR)

P. Benato MD; M. Zanatta MD; A. Barchitta MD; C. Pirozzi MD; V. Cianci MD.

Early and effective chest compressions have a well known pivot role in cardiopulmunary resuscitation (CPR) and 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) have strongly reinforced its importance.

The efficacy of chest compressions depends on hands position and on compression technique (frequency and depth).

Medical education and training can easily improve chest compression technique, while the choice of thoracic landmark is always blind even if 2010 consensus indicated that it is reasonable to place the hands in the lower half of the sternum.

Critical care ultrasound (CCUS) has changed the approach of critical ill patient, transforming blind medicine into visual medicine and can identify potential reversible causes of cardiac arrest during CPR.

Our challenge is to use CCUS to locate the most appropriate site for chest compressions.

We planned a pilot study (in progress) to evaluate the capability of critical echocardiography to improve the quality of chest compressions with a subcostal view while CPR is taking place.

We presented data of a small case series from 6 non traumatic cardiac arrests who had been treated both in-hospital and in pre-hospital settings.

In 3 out of 6 patients compressions were correctly performed and passive left ventricle contractility was guarantied. In the other 3 cases partials left ventricle compression or the narrowing of the base of the heart and aorta was observed. Ultrasound guided changes in hands position improved passive left ventricle contractility in the 3 incorrect CPR.

Our study doesn’t permit to estimate if the changes made in hands position would have affected the outcome of CPR.

Anyway we think that the possibility to focus the power of the hands over the real position of left ventricle certainly improves the quality of our chest compressions.

Introduction: European Society of Cardiology advocate the period and management of coronary reperfusion, primary percutaneous coronary intervention (pPCI) or thrombolysis, according to the interval between the beginning of chest pain (symptoms onset) and the first medical contact (CP-FMC) and the availability of pPCI. The objective of the study was to investigate the mortality of acute coronary syndromes with ST-segment elevation (STEMI) according to the recommended time and availability of pPCI.

Materials and methods: Data collected on a regional level through a retrospective study managed by 8 out-of-hospital emergency medical services (EMS) and 40 mobile intensive care units (MICU). Inclusion criteria: data collected from 2003 to 2013, all uncomplicated STEMI with symptom onset < 12h, with a pre-hospital decision taken for direct pPCI, arriving alive at the hospital. The area was divided into three concentric zones: city, inner and outer suburb. Availability of PCI was defined as the concentration of cath lab per 100 km2. Time intervals were defined in three categories according to the guidelines: target time (pPCI < 60min if CP-FMC < 2h or < 90min if CP-FMC between 2h-12h), reasonable time (pPCI between 60 and 120 min if CP-FMC < 2h or between 90 and 120 min if CP-FMC between 2h-12h) and out of time in the other cases. Chi-2 test was used for testing the trends, statistical significance p < 0.05.

Results: Data on 10,210 patients were recorded in 10 years, 2,454 (24%) received thrombolysis and 7,756 (76%) pPCI. Availability of PCI was 9.5 per 100km² in city, 2 in inner suburb and 0.1 in outer suburb. A significant increase of out of time PCI was found when access to PCI decreased (city 6% < inner suburb 9% < outer suburb 14%). Time delay to PCI were in target time for 16% (n=1,619), in reasonable time for 49% (n=5,026) and out of time for 11% (n=1,111). Mortality was significantly (p<0.0001) related to increased reperfusion period: in “target time” mortality was 1.8% (n=28), in “reasonable time” 1.9% (n=94) and in “out of time” 4.3% (n=46). Data were missing or uninterpretable in 3% of cases.

Discussion: Management of STEMI reperfusion is in target time for 16% of patients and 65% within acceptable time. PPCI-related “out of time” delay increased when availability of pPCI decreased. The clinical impact of non-compliance with time intervals is a major significant increase in mortality. These objectives legitimized by international guidelines must be implemented and respected.

Introduction : The Acute Coronary Syndrome with ST- segment elevation (STEMI) is a priority in emergency medicine. Do patients >= 80 years benefit from a management comparable to that of younger patients?

Objectives: Compare the characteristics of management of STEMI patients >= 80 years and

Methods: Data are derived from a prospective registry that lists all STEMI managed within 24 hours by 8 out-of-hospital emergency medical services (SAMU) and 40 mobile intensive care units (MICU) in a region of France. Secondary transfers were excluded from the analysis. Statistical analysis: Chi-2 test and Wilcoxon test were used. Multivariate analysis with reference group patients over 80 years old.

Results: 18,093 STEMI were included from 2003 to 2013 with 2,502 (14%) being >= 80 years. The proportion of elderly patients is stable since 2003. There was a majority of women (51% were over 80 years). The call to SAMU is delayed after the beginning of pain, since this call is made on average after 93 minutes for those aged over 80 as opposed to 57 minutes. Given these delays, the occurrence of at least one criterion of gravity was more common in those aged more than 80 years (29% against 18% in those aged less than 80 years). During the treatment, the decision of an unclogging was less frequent in patients >= 80 years of age 83% against 97% in patients aged less than 80 years, but when the decision was taken to unclog, primary angioplasty was carried out similarly in both groups. After adjusting for sex, age < 80 years remains an independent criterion for decision-making of an unclogging (OR = 3.5 [3.1 to 4.0], p <0.0001). Pre-hospital mortality was therefore greater for those above 80 years (1.3% against 0.5%), similarly, in-hospital mortality (15.7% against 3.8% in those under 80 years).

Discussion: The management of STEMI patients >= 80 years was associated with less reperfusion decisions than in younger people. However, to call to SAMU allowed to take the decision of unclogging in 83% of cases. The lack of decision-making certainly contributes to the excess mortality among those aged >= 80 years.

Objective

Pulmonary embolism (PE) has a heterogeneous clinical presentation and international guidelines recommend the use of validated clinical scores to estimate the pre-test probability of PE. Recently, point-of-care ultrasonography has been widely used, proving to be accurate and useful in the diagnosis of deep venous thrombosis (DVT) and of many acute pulmonary pathologies. The aim of this multicentric prospective study is to compare the diagnostic accuracy of a clinical-ultrasonographic score (US-WS) with a clinical score as Wells score (WS).

Methods

We calculated the dichotomized WS (“PE likely” if >4 points, “PE unlikely” if ≤4) in consecutive adult patients suspected of PE presenting to four italian hospitals. In each patient lung and venous ultrasonography were performed by a physician blinded to clinical data. The US-WS differs from traditional WS in the following items: “signs and symptoms of DVT”, replaced by “evidence of DVT at venous lower limbs ultrasonography” and ”alternative diagnosis less likely than PE” replaced by ”alternative diagnosis less likely than PE after lung ultrasonography”. The last item was considered positive in presence of at least one subpleural infarct; in absence of lung infarcts and in case of an alternative echographic diagnosis such as pneumonia, pleural effusion or diffuse interstitial syndrome, the item was considered negative. Finally, in case of a normal lung US examination, the item had the same point assigned to the same item in the WS. Final diagnosis of was obtained by multidetector CT pulmonary angiography or when not feasible by lung scintigraphy and a 30 days clinical follow-up.

Results

Among the 339 enrolled patients, PE was finally diagnosed in 96 (28.3%). Two-hundred (59%) patients had a WS ≤4, and among them PE was present in 41 (20.5%). In the 139 patients (41%) with WS >4, PE was diagnosed in 55 (39.6%).  Lung and venous ultrasonography was performed in 7±3 minutes. US-WS was ≤4 in 247 patients (72.9%, p<0.05 vs WS), of which 30 (12.1%) had PE as final diagnosis. In the 92 patients with US-WS >4 (27.1%, p<0.05 vs WS), 66 (71.7%, p<0.05 vs WS) had PE as final diagnosis. US-WS reallocated 85 patient (25.1%), moving 66 patients from PE likely to PE unlikely (only 7 had PE) and 19 patients from PE unlikely to PE likely (18 had PE). Sensitivity (68.8%, 95% CI 58.5-77.8) and specificity (89.3%, 95%CI 84.7-92.9) of US-WS where significantly superior to sensitivity (57.3%, 95%CI 46.8-67.3) and specificity (65.4%, 95%CI 59.1-71.4) of Wells score (p<0.05 for both). The area under the curve of US-WS (86.6%, 95% CI 81.9-91.4) was significantly superior to that of WS (64.5%, 95% CI 57.7-71.2)  (p<0.05).

 Conclusion

The US-WS is rapidly feasible at the bedside, increases the proportion of low-risk patients with a better global accuracy compared to traditional WS.

Background: Several studies examined the impact of off-hour presentation (cath lab staff available on call) on both the processing time of patients with ST-elevation myocardial infarction (STEMI) and the resulting outcomes. There is general agreement in the literature with regard to the importance of the processing timing of the patients, although data regarding increase in mortality as a function of processing timing are conflicting.

Objective: To evaluate the association between off-hour presentation, door-to-balloon time (D2B), first medical contact-to-device (FMC2D), total ischemic time (TIT) and in-hospital and 30 day mortality in patients with STEMI.

Methods and results: Through a retrospective analysis, we examined the medical records of patients admitted for STEMI documented within 12 hours from symptoms onset, who underwent an emergency PCI in a hub hospital in the period spanning from 01/01/11 to 12/31/14.

A total of 525 patients were included in the study; 352 of them (67%) reached to hospital in a moment of inactivity of the cath-lab (off-hour) with all or part of the staff not physically present, while 173 (33%) presented themselves during the hours of service of the cath-lab (on -hour).

The two groups were homogeneous for sex, age ≥75 years, cardiogenic shock, and bradycardia. The delay in seeking relief was similar in the two groups, significant differences emerged with regard to D2B, FMC2D and TIT; patients who arrived during off-hours showed longer D2B (median 65 'vs. 49', p<0.001), FMC2D (median 95.5 'vs 84 ', p<0.001): reperfusion was achieved less frequently in a time interval consistent with guidelines (≤ 90% FMC2D': 45.5% vs 56.2%, p=0.036, OR 0.65, 95 % CI 0.43 to 0.97); TIT was similar in the two groups (median 200 'vs 185', p=0.348).

These differences in time of reperfusion are confirmed after adjustment for age, sex, and access modality (emergency service vs self-presentation).

The in-hospital mortality was higher in patients presenting during off-hours (7.1% vs 2.3%, p=0.024, OR 3.24, 95% CI 1.11 to 9.46): 30 day mortality was also different although it did not reach the statistical significance (7.7% vs 3.4%, p=0.06, OR 2.33, 95% CI 0.94 to 5.74).

Conclusions: In our working setting patients with STEMI presenting during off-hours had revascularization times significantly higher: this data are associated with a significantly higher in-hospital mortality. These data highlight the need of improving the cath-labs organization as well as rationalize the allocation of resources in order to ensure adequate revascularization times to all patients with STEMI to improve significantly both clinical outcomes and survival.

Background: Several biological prognostic indicators were analyzed in the acute heart failure syndrome (SICA) such as: hemoglobin, serum sodium, troponin levels…Initial hyperglycemia appears among these prognostic indicators (1).

Purpose: The objective of this work was to investigate the prognostic impact of the initial elevated blood glucose on mortality among patients with SICA admitted to the emergency department.

 Participants and methods: We conducted a single- center, prospective, observational study. Inclusion of patients with SICA. Standardization of treatment according to clinical scenario (CS). Hyperglycemia was defined as:

- Diabetic known patient or unknown but with HbA1C ≥ 6.5%:  hyperglycemia if glucose level ≥ 11mmol /L.

- No diabetes with HbA1C < 6.5%: hyperglycemia if glucose level ≥ 7mmol /L.

Results: One hundred eighty patients were included. Mean age= 66 ± 11 years [22-94]. Sex ratio= 1.27. Clinical history N (%): Hypertension 147 (81.7), known diabetes 124 (68.9). The distribution by clinical scenario N (%)   : CS1: 121 (67.2), CS2: 14 (7.8), CS4: 44 (24.4), and CS5: 1 (0.6). Twenty three patients had an HbA1C test which allowed tracking 8 unrecognized diabetes (HbA1C ≥ 6.5%). Average blood glucose concentration at admission was 15.65± 8.4 mmol/L [3.3 - 44]. The initial hyperglycemia was noted in 128 patients (71. 1%): 96 diabetic, 32 without diabetes. Overall 21 patients (11, 7%) died during 30 days of follow-up, 24 patients (13, 3%) died during 90 days of follow up. Mortality at one month was significantly elevated in patients with initial hyperglycemia [14, 8% (n= 19) vs 3, 8% (n=2); p = 0,041]. The same difference was demonstrated at 90 days follow –up [17,1% (n=22) vs 3,8 % (n =2 ); p = 0,016).

Conclusion: Elevated blood glucose concentrations at presentation are associated with one month and  three months mortality in acute heart failure syndrome admitted in emergency department.

(1): Mebazaa  and al . J Am Coll Cardiol 2013; xx: 1-10

INTRODUCTION / BACKGROUND

Emergency Departments (EDs) are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction

In an era of ED overcrowding, an efficient triage system is essential because it allows the emergency team to treat patients according to the urgency of their condition

AIMS, MATERIALS / METHODS

A triage liaison provider may be a way to improve ED throughput, when additional staff resources are available, in an effort to improve patient satisfaction, decrease waiting time (WT), improve clinical care and decrease lost revenue from patients leaving without treatment.

A senior experienced nurse, with known both technical and non-technical skills, was added in the ED, during daily shifts (h 8-14 and 14-20) in working days, acting after the usual nurse triage protocol, and before the Medical Doctor (MD) taking charge of the patient.

His tasks, as a Flow Processing Manager (FPM), were:

- to upgrade triage evaluation process and improve throughput efficiency in a timely manner,

- to early identify time-dependent situations (by clinical or welfare conditions) and outliers,

- to redirect and address (according to the instant picture of the ED) the specific patient (according to his acuteness, frailty and complexity), to a specific route (according to the need for less or more intensive care), and to a specific MD (according to his expertise, and being more or less busy).

We performed a prospective “before and after” cohort study, in the ED of a University Teaching Hospital, from 08/4/2012 to 07/4/2013, and from 08/4/2013 to 7/4/2014, to assess the impact of FPM in terms of WT, rate of outliers, patients Left Without being Seen (LWS), and MD performances.

RESULTS

We compared “before” (control group) and “after” (intervention group) data (respectively):

the number of triaged patients augmented (67400 “before” versus 70922 “after”);

waiting times (media; in minutes.seconds) slightly changed depending on “triage code” (red 7.04 versus 7.02; yellow 15.32 vs 21.25, green 84.10 vs 88.07, white 88.55 vs 78.04);

total time spent in the ED (media; in minutes) dramatically changed depending on “triage code” (red 221 versus 940; yellow 988 vs 1159, green 218 vs 699, white 161 vs 177);

the number of patients admitted slightly increased (24687 versus 24759);

LWS rate decreased (1135 versus 741).

CONCLUSIONS

In the ED the introduction of an additional experienced nurse provider as FPM showed the ability to ameliorate patient throughput, waiting times and LWS rates, improving both safety and quality of care, even coping with the dramatic increase in length of staying due to overcrowding and shortage of beds.

ED waiting rooms are high liability areas for hospitals: opposite to trends towards overall increasing risks, the addiction of a FPM can actually reduce risks in individual patients

Introduction: patients in the resuscitate room (or shock room) are considered the most critically ill patients and correspond to 4-5% of vital distresses in an ED according to literature. Our main objective is to optimize its use and thus provide a better quality of care.

Materials and Methods: A retrospective comparative analysis of patients treated in the shock room during 3 years (2012-2014) in a General Hospital ED since the implementation of a 24 hours/day dedicated resuscitate Team composed by the prehospital EMT (senior Emergency Physician, nurse and nurse aide). Patients’ demographic data, diagnoses and outcomes were accessed. Comparison of patients chief complaints to Nurse and Physician Triage, analyze of Waiting Time (WT), Length of Stay (LOS).

Results: In the last 3 years among 41000 visits / year in the ED, the absolute rates of emergency room utilization rose, the rate of unstable patients demanding urgent intensive care regularly increase with a mean number of 445 patients / year (4% of all admissions) in 2014. Sex Ratio 60 Male /40 % Female. Average age 62.7 years. Most important activity on Monday 16.5% vs 11.5% on Saturday, hourly peak 11-12 AM 7.1% vs 3% 9 / 10am activity increased in winter 34.6% vs 27.5% in summer. Neuro-vascular disorders (18%) multiple trauma (15.6%) and respiratory distress 12.4% . Before their admission in the ED, 39 % of patients were managed by prehospital EMS . A majority of these patients had severe Triage level (1-2) but 52% of patients were initially in the general ED ward and not in the shock room. The LOS in the resuscitate room is 2 hours for 66% of patients and remains stable despite the increasing activity of ED visits. Patients were oriented to the intensive care unit (31%), Observation Unit (26%) or transferred (10%) in other centers.

Discussion: our study highlights essential points for the initial triage and the impact of a LOS on morbidity /mortality for critically ill patients .Optimal management of the shock room with regular training of multidisciplinary medical team to determine whether subjects need immediate admission to the shock room. Risk management precautions dictate that under no circumstances would an unstable patient remain in the open triage section of the emergency room under inferior surveillance and need to stay immediately in the shock room. A new protocol with the Triage Team is in progress to evaluate the impact on the management of the shock room.

Conclusion: management of the shock room is an important part of the treatment chain of the severely injured patients in the Emergency Department. Successful management in the resuscitate room requires a reliable and effective tailored guidelines for evaluation and decision protocol of Triage and regular evaluation of patients in the ED.

A New Model of Urgent Care Centre in the

Emergency Departments of the United Kingdom

Abstract

Introduction:  Primary Care patients in the accident and emergency departments have been the topic of discussion since 1998 in the United Kingdom.  Numerous studies have analysed attendances retrospectively and suggest that at least one third to two thirds of patients attending the emergency department with problems which could be managed appropriately in General Practice.  The pattern of emergency department usage seems to be international.  Outside the United Kingdom in Australia and many departments in the United States include walk in facilities.  Staffed by Physicians on family practice residency programme.  It clearly appears in the United Kingdom that emergency departments have to accept that such patients with primary care problems will attend the emergency department and facilities will have to be provided to provided services to these patients. 

Urgent care centres were developed near the accident and emergency departments to reduce the pressure on the emergency departments.  Unfortunately this has not happened.  It has been noticed that when more patients are seen in Urgent Care Centres the number of attendances in emergency departments increase as well. 

Objective:  We started a new model of Urgent care centres where the urgent care centre was located in the emergency department and is staffed by a General Practitioner and a Senior Doctor in the department.

Method:  We studied the number of patients, type of patients and the time it took for the patients to be seen in the Urgent Care Centre. 

Results:  Our Urgent Care Centre has been running for the last six months and we have seen a gradual increase in the number of patients being seen from 6.89% to 46.85% now.  Most of these patients were in the category 4 and 5 according to the Manchester Triage System. 

Discussion:  It has been recognised that primary care patients in the Emergency Department are a major part of attendances of the Department and unless the patients are seen in Urgent Care Centres, overcrowding and long waits in the Emergency Department could not be avoided.  It has been shown that employing Primary Care Physicians in the Emergency Department reduce the costs of Emergency Departments because Primary Care Physicians do not carry out as many investigations as by the junior doctors in the Emergency Department and the number of admissions are reduced as well.

Conclusion:  None of the patients had to wait for more than two hours to be seen in the Urgent Care Centre and we feel that the care provided to the patients by the Urgent Care Centre is highly effective, reduces costs and is satisfying for the patient.

Background:

Emergency Department (ED) patient attendances have an inherent variability during certain periods of the day and month to month¹. Predictability of this pattern helps in planning adequate staffing ratios and allocating resources. During the month of Fasting (Ramadan), healthy adult Muslims do not eat or drink from dawn to dusk². During this month, in the Middle East, there is a significant change in the sleep-wake pattern of the society³.  It is not known, if these social and cultural factors affect the ED attendance pattern.

Objectives:

This is a retrospective study of ED patient attendance variability in the day and night shift during Ramadan, in a tertiary care hospital of a country with a predominantly Muslim population. This will improve understanding of patient presentation patterns and will assist managers to align resources with the patient care presentation.

Method:

The data was retrieved from the Hospital’s integrated clinical information system (ICIS). All ED visits during the Islamic calendar year of 1432 (December 7, 2010 - November 25, 2011) were included. Direct admissions to the hospital are excluded. Descriptive statistics for the continuous variables are reported as mean± standard deviation and categorical variables are summarized as frequencies and percentages. Continuous variables are compared by Student’s independent t-test or ANOVA as appropriate; while categorical variables are compared by Chi-square test. The level of statistical significance is set at p<0.05. The statistical analysis of data was done by using the software package SAS version 9.3 (Statistical Analysis System).

Result:

A total of 58,859 patients presented to ED, 33,602 (57.09%) were during the day shift (0700 to 1900 hrs.) and 25,257(42.91%) during the night shift (1901 to 0659 hrs.). A total of 50,470 patients (85.75%) were discharged home and 5,142 (8.73%) were admitted to the hospital. Average monthly patient visits during the day were 2,800 (57%) and 2,105 (42%) during the night shift. There was a statistically significant difference in the arrival time of the patients during Ramadan and the attendance pattern was reversed; 1614 (39%) patient during the day and 2,568 (61%) during the night shift (p<0.0001) (Table 1). However, there was no statistical difference in patient admissions and discharges (p>0.1).

Conclusion:

ED patient attendance pattern changed during Ramadan with greater number of patients presenting during the night. Therefore, allocation of resources in ED of tertiary care Hospitals of predominantly Muslim populations, should match the nocturnal arrival pattern of the patients.

I am Dr Anantha Nag Kadiyala, an Emergency medicine Consultant working in United Kingdom at Bradford Royal Infirmary. I would like to present this excellent software tool which would benefit Emergency departments to maintain and monitor safety. College of Emergency Medicine (CEM) books is a suite of mobile & web applications designed by NHS consultants and managers being used in emergency departments (ED) to better understand the demands on their systems, share information and make intelligent informed decisions. Users quickly enter logs and situation reports with live metrics of personalised performance indicators. These are analysed to give an overall visual status of a department and predict performance. Status and issues are escalated to key individuals able to enact immediate responses. In app access to key documents, phone numbers and web links promotes real time consistent adherence to current trust policies.

Features: 

1. Situation Reports: Structured assessments of your department’s key performance indicators could be quickly entered to create a comprehensive understanding of departmental status.

2. Handover: Capture departmental handovers in an accessible, retrievable and searchable format. It uses the Royal College approved ABCDE handover structure with added personalised features specific to the department.

3. Log Book: Quickly enter structured situation, background, assessment & recommendation (SBAR) logs detailing important events and interactions. This would help sharing the experiences and difficulties by the staff working in the department. These logs can be tagged to categorise and identify the themes targeting important issues.

4. Escalation & Sharing: Relevant Information is escalated vertically and shared horizontally across the organisation allowing team members to see and respond in real time.

5. Analysis: Key Performance Indicators could be visualised by hour, day, week & month. Recurrent themes could be searched by using tags. The status of the Emergency department could be divided into three categories (red, amber and green) depending on the safety. For e.g. Indicators of emergency department of Bradford Royal Infirmary are as follows.

1. Patient Vs doctor ratio
2. Ambulance hand over time
3. Time to triage 
4. Capacity of resuscitation room, paediatric, majors and minors cubicles
5. Average time to see a patient in each area of the department 
6. Number of senior doctors, Nursing staff
7. Number of patients awaiting beds
8. Specialist review time in ED

6. Notifications: Notifications can be sent as in app push messages, emails or text messages. Notifications could be tailored according to the personal need.

7. Feedback: Staff requested friends and family feedback ensures local ownership and control. Feedback is anonymously linked to staff members, teams, and live departmental performance. Paper and administration free system promotes personal, team and business values.

8. Rule Book: Immediate access to all relevant departmental documents. Built in governance structure to ensure only approved current guidance with clear ownership & expiration dates will be available.

9. Phone Book: Immediate access to all relevant departmental phone numbers. It foregoes the need for landlines and calls to switchboard operators. Personalised favourites lists could be created if necessary.

April 2015 we have moved to a new emergency department (ED) with less treating positions while there is a steady increase in the yearly number of patients.  Because in the former ED we were already facing flow problems with an increasing length of stays (LOS) we decided to change policies in order to accelerate flow in the ED and between the ED and the hospital.  A previous study showed that the introduction of an observation unit (OU) could help to guarantee patient flow in the ED. Therefore a 30-bed OU is deployed in the new hospital.  The aim of this preparatory study was to estimate the required number of beds in the OU. The number of beds needed was calculated by discrete event simulation using Arena Software (Rockwell Software). The model maps the patient flow in the ED and between the ED and hospital wards like the OU. Input in the model were admission pattern, interval times for clinical, diagnostic and therapeutic ED interventions, LOS in both the ED and the hospital of a representative sample of 4734 patients, admitted to the ED between October, 1st 2012 and September, 30^th 2013. The model allows to estimate the number of observational beds needed for several scenarios. In all scenarios, it was assumed that all patients first are transferred to the OU before they eventually are admitted to another hospital ward, except for 33% of the patients in need of special care  like intensive care, obstetrics, psychiatry or paediatrics. Another basic rule was a maximal LOS in the OU of 48h. In order to get a grip on the capacity range of the OU, we introduced different what-if scenarios with variability in the LOS of the ED and the OU. For the ED the values for LOS were not truncated (no maximum) or truncated at a maximum of 8h, 6h and 4h in four different scenarios. For the OU the maximal LOS was 48u but the peak of the triangle distribution of LOS was set at 24, 30 or 36h. Combination of different scenarios for the LOS at the two levels of the ED and the OU induce differences in the needed capacity of  the OU. The results of the study show that the P75 of required bed positions in the OU range between 26 (no maximal LOS in ED combined with peak LOS in OU of 24h) and 34 (LOS in ED maximal 4h, peak LOS in the OU of 36h). Discrete event simulation, if based on a representative database, allows to map patient flow revealing bottlenecks and to perform what-if scenarios for capacity without disturbing the real life practice.  This approach helps to choose the best  scenario to optimize  the  patient flow in the future ED to the OU with 30 positions. The model shows that the OU cannot handle all admitted ED patients and therefore some ED patients will still have to be admitted directly at the correct hospitalisation ward bypassing the OU.

 Background

 The health care reform of the last years in Italy brought to a significant reduction of hospital beds for acute admission and the Emergency Departments (ED) have to intervene on the organisation of more structured Observation Units (OU) in order to observe and treat patients with a high probability of early discharge, who need a management longer than 6 hours (limit for a simple ED visit). In general, the maximum length of day in the OU is 30 hours.

In many regions of Italy the OUs have been structured with dedicated beds and organised with specific protocols for some pathological conditions. In the Piedmont region such protocols have some defined outcome indicators, previously established and reviewed periodically. In other regions such process is in progress and specific protocols are not yet available.

Methods

In this study we have compared the performance of the EDs of two secondary hospitals: the first, in Piedmont region (S. Andrea hospital, Vercelli), with a structured OU and defined protocols and the second, in Marche region (S. Lucia Hospital, Macerata), without a structured OU. We have focused the attention in the management of 4 specific conditions-atrial fibrillation (AF), hypoglycaemia, epilepsy/seizures, head injury-to assess the adherence to such indicators. The results of Macerata hospital have been evaluated according to the indicators of Vercelli.

Results

In Vercelli hospital the ED visits were 30348 from January to December 2013; the overall admission rate was 12.5% of the admissions; 3893 pts were kept in the OU (12,8%) and among them 751 were admitted after the observation period (18,8%).

In Macerata hospital the 2013 ED visits were 29686 and the overall admission rate was 20.2%; 1451 patients were kept in the OU (4,89%) and the admissions were 596 (41,1%).

The mean length of stay in the OUs was around 18 hours in both hospitals.

The outcome indicators for the 4 protocols considered were: AF <5% admissions, Hypoglycaemia <10% admissions, Epilepsy/seizures <30% admissions, head trauma 100% CT scan in anti coagulated patients.

All the outcome indicators have been respected by the Vercelli OU, while the admission rate for AF in Macerata was 14%, for Hypoglycaemia 60%, for Epilepsy 46%. The head trauma indicator was met in both hospitals

Conclusions

A structured OU allows to increase the number of patients observed and to decrease the total number of admissions, improving the appropriateness with a rational use of hospital beds.

The presence of specific protocols allows to better categorize patients and to evaluate the appropriateness of the interventions according to the relative outcome indicators.