Monday 03 October
08:30

Monday 03 October

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KS1
08:30 - 09:00

Keynote Session 1

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester)
08:30 - 09:00 Clinical Decision Making in the Resus Room. Simon CARLEY (Consultant in Emergency Medicine) (Manchester, United Kingdom)
Room A-FESTSAAL
09:10

Monday 03 October

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A21
09:10 - 10:40

State of the Art
Pre-hospital

Moderators: Dr Abdo KHOURY (Senior attending Physician) (Besançon, France), Eric REVUE (Chef de Service) (Paris, France)
09:10 - 09:40 Capnography in Prehospital Medicine. Stefan TRENKLER (Košice, Slovakia)
09:40 - 10:10 Prehospital Stroke Management. Eric REVUE (Chef de Service) (Paris, France)
10:10 - 10:40 The efficiency of helicopter emergency missions for STEMI: Time and intervention. Carmen Diana CIMPOESU (Prof. Head of ED) (IASI, Romania)
Room A-FESTSAAL

Monday 03 October

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B21
09:10 - 10:40

Austria, Germany, Switzerland Invites
Politik und Qualifikation

Moderators: Robert SIEBER (Switzerland), Christian WREDE (Germany)
09:10 - 09:40 Facharzt Notfallmedizin in der Schweiz: nächste Schritte. Robert SIEBER (Switzerland)
09:40 - 10:10 Struktur der Notfallversorgung. Christian WREDE (Germany)
10:10 - 10:40 Entwicklung der notfallmedizinischen Supraspezialität in der Schweiz. Ulrich BÜRGI (Switzerland)
Room B-ZEREMONIENSAAL

Monday 03 October

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C21
09:10 - 10:40

Philosophy & Controversies
P&C Pain Management & Procedural Sedation

Moderators: Philip EISENBURGER (Head) (Vienna, Austria), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, Germany)
09:10 - 09:40 The painful following of clinical guidelines - does implementation of clinical guidelines improve pain management in the ED? Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada)
09:40 - 10:10 Intubation of the not fastened patient for procedural sedation - the safer option? Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, Germany)
10:10 - 10:40 Alleviating symptoms and generating them at the same time - Ketamine for agitation and delirium? Andy NEILL (Doctor) (Dublin, Ireland)
Room C-PRINZ EUGEN SAAL

Monday 03 October

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D21
09:10 - 10:40

EUSEM meets ERC

Moderators: Maaret CASTREN (Professor) (HELSINKI, Finland), Marc SABBE (Medical staff member) (Leuven, Belgium)
09:10 - 09:40 Resuscitation academy. Maaret CASTREN (Professor) (HELSINKI, Finland)
09:40 - 10:10 A new way to produce and use guidelines. Koen MONSIEURS (Director) (Antwerp, Belgium)
10:10 - 10:40 ERC Guidelines for traumatic cardiac arrest: Why was the approach changed. Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, Czech Republic)
Room D-FORUM

Monday 03 October

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E21
09:10 - 10:40

Research
Geriatric

Moderators: Jay BANERJEE (Leicester, United Kingdom), Pr Abdelouahab BELLOU (Research) (Boston, USA)
09:10 - 09:40 The Boarding Patients in the ED: Are Older Patients the Major Cause ? Pr Abdelouahab BELLOU (Research) (Boston, USA)
09:40 - 10:10 Assessing for Cognitive Impairment in Older Patients: Results of the UK Clinical Audit. Jay BANERJEE (Leicester, United Kingdom)
10:10 - 10:40 Pre-Hospital Initiatives to Decrease the Number of Older Patient ED visits. James WALLACE (Consultant in Emergency Medicine) (Warrington, United Kingdom)
Room E-GEHEIME RATSTUBE

Monday 03 October

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F21
09:10 - 10:40

YEMD
Developing your portfolio career

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Amy HUGHES (Cambridge, United Kingdom)
09:10 - 09:40 A career in Emergency, Pre Hospital, Humanitarian and Disaster Medicine. Amy HUGHES (Cambridge, United Kingdom)
09:40 - 10:10 Over and above service provision: pathways to developing portfolio interests as a trainee. Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom)
10:10 - 10:40 Adventure and Education in a University Emergency Department and in the Himalayas. Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, Switzerland)
Room F-RITTERSAAL

Monday 03 October

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G21
09:10 - 10:40

Paediatric track
Hot Topics

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Silvia BRESSAN (Moderator) (Padova, Italy)
09:10 - 09:40 Set 1 - In situ simulation in the PED: pros and cons. Marco DAVERIO (Padova, Italy)
HFNC use - steps towards evidence based practice.
09:40 - 10:10 Set 2 – Point of care US: tips and trick for the PED. Mark HADEN (London, United Kingdom)
Telemedicine: new frontiers and barriers
10:10 - 10:40 Set 3 – High-tech PEM: how technology can make your life easier. Johan SIEBERT (Genève, Switzerland)
Room G-GARTENSAAL

Monday 03 October

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OP21
09:10 - 10:40

Oral Papers 21

Moderators: Dr Kim GEYBELS (Emergency and prehospital physician) (Sint-Martens-Latem, Belgium), John HOLCOMB (USA)
09:10 - 09:20 #7469 - OP028 The Physiology component of Trauma Triage Tool has the highest PPV.
The Physiology component of Trauma Triage Tool has the highest PPV.

Introduction: Injuries are a major cause of morbidity and mortality in both developing and industrialized regions 1.  Injury severity scores are simply a way to describe and quantify the severity of traumatic injury and also provide some sense of the probability of survival of the victims2. The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury 3.This study aims at evaluating the component of trauma triage tool with highest positive predictive value to identify major trauma patients.

Objective:

 

To determine the component of pre-hospital tool (Trauma Triage tool) with highest positive predictive value?

 

 

Methodology:

 

 A Retrospective database analysis of Major trauma patients presenting to QEHB during the period January 2013 to January 2014 was performed. All Major trauma patients (TTT positive) presenting to QEHB during this period were included.  The patients who were TTT Negative were excluded.

 

Data were coded and entered on Excel file and statistical analysis was done using the Statistical Package for Social Science (SPSS) version 16.0. Descriptive analysis was conducted to determine the sensitivity and specificity of pre- hospital TTT and each of its components (vital signs, anatomy, injury mechanism and special conditions). Pearson Chi- Square test, Fisher’s exact test and Independent Student's t- test were used to evaluate the association between the severity of injury and certain variables: Mechanism of injury, Glasgow Coma Score (GCS) level and patient's age.

 

 

 

Results:

There were 694 trauma patients presented during study period. Only 597 patients met the inclusion criteria and were included in the study. The majority of our sample was male (70.7%), with a mean age of 53 years. About one third of these patients had involved in RTCs. Approximately 60 % of the study group had been alerted in as major trauma cases.

Out of the 597 trauma patients, 316 patients were identified as a major trauma cases (true positive cases) that had an estimated ISS more than 15 (Positive Predictive Value (PPV) = 0.529 at 95% CI 0.49, 0.57; p= 0.000).

The Trauma Triage Tool consists of four components: Vital signs, Anatomy, Mechanism of injury and Special conditions. The Physiology component had the highest PPV of 0.79 at 95% CI 0.73, 0.85, which was followed by the Mechanism of injury with PPV equals 0.618 at 95% CI 0.55, 0.69, then the Anatomy component (PPV= 0.523 at 95% CI 0.46, 0.69), then the Special conditions components which had PPV of 0.448 at 95% CI 0.39, 0.51.

 

Conclusion:

Within the pre-hospital management of seriously injured trauma victims the accuracy of the field triage is of utmost importance. The clinicians significantly depend upon the pre hospital information to activate the resources.  Hence greater the PPV of TTT better the trauma team remix can be planned.

Our results clearly suggest the correlation of abnormal physiological parameters with high probability of ISS>15. Even when combined with other components of the TTT the PPV of the physiological component remains the highest.

M Azam MAJEED (Birmingham, United Kingdom), M Saif REHMAN, Asif NAVEED, Shereen NABIL
09:20 - 09:30 #7049 - OP029 Compared analysis of London, Boston and Paris attacks : learning from each other to become stronger.
OP029 Compared analysis of London, Boston and Paris attacks : learning from each other to become stronger.

Background

In 2005, 2013 and 2015 respectively, London, Boston and Paris (November events for this study) were targeted by major terrorist attacks. Despite their differences these attacks caused many common difficulties and issues for rescue organizations in countries with mass casualty plans that differ widely. The aim of the present study was to analyze and compare the specific responses of each city to a similar kind of crisis.


Participants and methods

We used publications and official reports about the London bombings [1], Boston bombings [2] and Paris terrorist attacks [3,4]. We detailed, when available, response timelines for each attack, the resources committed, the pre-hospital organization and hospital dispatch. 


Results

In London, 4 suicide-bomb attacks (3 aboard London Underground trains and 1 on a double-decker bus) killed 52 civilians and injured over 700 more. In Boston, 2 pressure cooker bombs placed near the finish line of the Boston marathon killed 3 civilians and injured 264 more. In Paris, suicide bomb attacks, mass shooting and hostage taking killed 130 civilians, including 89 on one closed site of mass shooting, and injured over 413 more. Three different dispatch strategies were used: proximity dispatching in London, equal pre-defined dispatching in Boston and regional partially medical dispatching in Paris. If not already activated, national crisis management facility was operational in less than 40 minutes. 7 to 17 hospitals were involved in caring the victims. In all cities, evacuation of the victims was achieved in less than about 6 hours after the beginning of the attack.

 

 

Discussion

Several key points can be extracted from the three responses. A pre-defined idea of the capacities of each hospital as well as a real-time assessment proved extremely helpful. A unique dispatch and control center allows a good overview of the destination of the patients. Dedicated communication channels between all the critical national infrastructures allow swifter alert of all the involved services. Good communication is always a major issue, particularly in areas where networks are saturated, switched off, degraded or destroyed. When the network is on, giving the right information to the right persons at the right time is both vital but very difficult. Mass casualties require material, vehicles and personnel in numbers that need to be organized in advance if we want to respond without delay. Dealing with the uncertainty of the situations and reacting quickly requires response systems that are simple and robust and that favor the autonomy of the operational teams. Finally, drills, exercising, and repeating procedures again and again are absolutely crucial if we are to be agile and effective in our responses. 

 

1. Report of the Official Account of the Bombings in London on the 7th July 2005

2. After Action Report for the Response to the 2013 Boston Marathon Bombings, dec 2014

3. Hirsch M et al., The medical response to multisite terrorist attacks in Paris, Lancet 2015 Dec 19;386(10012):2535-86.

4. Lesaffre X, Attacks on Paris: what can we learn, oral presentation

Sophie MONTAGNON, Xavier LESAFFRE (Paris), Daniel JOST, Stéphane BOIZAT, Olivier BON, Michel BIGNAND, Patrick PLAISANCE, Jean-Pierre TOURTIER
09:30 - 09:40 #7126 - OP030 Major incident triage: the civilian validation of the Modified Physiological Triage Tool (MPTT).
OP030 Major incident triage: the civilian validation of the Modified Physiological Triage Tool (MPTT).

Introduction:

Triage, the process of categorising patients based on clinical acuity, is a key principle in the effective management of a major incident (MI).  There are at least three different triage systems in use worldwide, and previous attempts to validate them have demonstrated limited performance. 

Using a military cohort and regression analysis, the Modified Physiological Triage Tool (MPTT) was developed and when compared to existing triage methods, demonstrated an improved performance at predicting need for life-saving intervention and yielded the lowest rate of under-triage (30.1%).  Within the adult civilian population, where blunt trauma predominates and there is an older population, no such work has been undertaken to develop an improved system of triage.

The purpose of this study was to perform a comparative analysis and initial validation of the MPTT within a civilian environment. 

Methods:

A retrospective review of the Trauma Audit Research Network (TARN) database was performed for all adult patients (>18 years) presenting to a UK Emergency Department (ED) between 1 January 2006 and 31 December 2014. Patients were defined as Gold Standard Priority One if they had received one or more life-saving interventions from a previously defined list.  Only patients with complete physiological data and who received treatment at a single hospital were included in the analysis.

Using first recorded physiological data (HR/RR/GCS/SBP), patients were categorised as Priority One or Not Priority One by the newly derived MPTT (12 > RR < 22, HR > 100, GCS < 14) and existing major incident triage tools (START - ST, CAREFLIGHT - CF, Modified Military Sieve – MMS and Triage Sieve – TS). Performance characteristics of all triage tools were evaluated using sensitivity, specificity and AUROC, and rates of over and under-triage were compared. AUROC were compared for triage tools with similar performance.

Results:

The TARN registry held records for 218,453 adult patients during the study period, of which 129,647 (59.3%) had complete data and were included in the analysis.  55% of patients were male, with a median age of 61 (range 18-111).  25,452 patients (19.6%) were defined as Priority One, with a median ISS of 9.  Blunt trauma predominated (96.5%), with falls < 2m the most common injury mechanism (53.9%).

The MPTT outperformed all existing triage methods with the highest sensitivity (58.1%) and demonstrated an absolute reduction in under-triage of 44.5% when compared to the existing MIMMS Triage Sieve.  With an AUROC increase of 1.3, ROC comparison demonstrated significance between the MPTT and MMS (c2 = 83.91, p < 0.001), statistically supporting the use of the MPTT.


Conclusion:

This study has defined the performance of the MPTT (a tool derived using a military cohort) in a civilian environment, where it has been shown to outperform all existing MI triage systems in its ability to predict need for life-saving intervention.  As a result of this validation, its use within a civilian major incident context is recommended.

 

 

Jason SMITH, James VASSALLO (Plymouth, United Kingdom)
09:40 - 09:50 #7176 - OP031 Additional value of d-dimer and the disseminated intravascular coagulation score in predicting outcome after out-of-hospital cardiac arrest.
OP031 Additional value of d-dimer and the disseminated intravascular coagulation score in predicting outcome after out-of-hospital cardiac arrest.

Background: Chances of survival in out-of-hospital cardiac arrest (OHCA) patients decrease with increasing duration of hypoperfusion. The pathophysiological changes after prolonged resuscitation efforts and consecutive hypoperfusion appears comparable to those in severe sepsis leading to post-resuscitation coagulopathy. The occurrence of overt disseminated intravascular coagulation (DIC) is associated with poor outcomes and high mortality risk in various medical conditions. Similarly, the occurrence of DIC in cardiac arrest patients seems to be associated with an unfavorable prognosis. 

Objective: Recent data suggest an overt DIC rate of 33% in OHCA patients with sustained return of spontaneous circulation (ROSC). The current study determined the prevalence of overt DIC, its association with outcome, and the predictive value of d-dimer in an Austrian collective of OHCA patients.

Methods: All patients with available coagulation parameters from 2006-2014 were extracted from a prospectively compiled OHCA registry. Primary outcome was the prevalence of overt DIC. Binominal logistic regression analysis was applied to ascertain predictors of overt DIC, 30-day mortality and neurologic outcome. The discrimination of the fitted logistic models was assessed using the area under the receiver-operating-characteristic (ROC) curve.

Results: Out of 1179 OHCA patients, coagulation parameters were available in 410 (72% male; 57years, 48-69). The rate of overt DIC was 10% (95%CI, 7-13; n=39) overall and 7% (95%CI, 5-10; n=30) in the sustained ROSC subgroup. The odds ratio for 30-day mortality (46%, 95%CI 41-51; n=188) increased with the DIC score and was 9.6 (crude OR; 95%CI, 3.7-25) in patients with overt DIC on admission (n=39). The regression model including d-dimer, lactate levels, no-flow interval and initial rhythm (χ2(4)=125.1; p<0.001; HLT=0.20) best predicted 30-day mortality (R2= 0.58); The inclusion of d-dimer levels into the model significantly increased the area under the ROC curve from 0.78 (95%CI, 0.73-0.85) to 0.90 (95%CI, 0.85-0.94; p=0.001).

Conclusion: The current study identified increasing no-flow intervals (indicating the extent of non-perfusion), a non-shockable initial heart rhythm and elevated lactate levels (indicating the magnitude of tissue hypoxia) as the main predictors of overt DIC patterns in OHCA. The inclusion of d-dimer levels into a prediction model, however, improved its accuracy, and d-dimer levels may serve as an additional, independent surrogate parameter to assess outcome in OHCA.

 

Nina BUCHTELE (Vienna, Austria), Bernd JILMA, Andreas SCHOBER, Christian SCHOERGENHOFER, Fritz STERZ, Michael SCHWAMEIS
09:50 - 10:00 #7419 - OP032 Ultrasound-Guided Reduction of Distal Radius Fractures.
Ultrasound-Guided Reduction of Distal Radius Fractures.

Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures

Anita SABZGHABAEI (TEHRAN, Islamic Republic of Iran), Majid SHOJAEE, Saeed HASANPOOUR, Taghian SAHAR
10:00 - 10:10 #7583 - OP033 Willingness to work of hospital staff in disasters, a national survey of the fight or flight study group.
OP033 Willingness to work of hospital staff in disasters, a national survey of the fight or flight study group.

Objectives: To evaluate the willingness to work of hospital staff and factors promoting it  in different mass casualty settings.

Background: When disaster strikes, getting care to the victims is at the top of everyone's attention. But who will provide that care? A part of the hospital personnel will be absent as they are inflicted in the incident whereas the management expects that the rest deploys a higher engagement to cope with the surge. However, care for inflicted family and fear of becoming a secondary victim could prevent people to go to work.

Material and methods:

4 groups (physicians, nurses, administration and supportive services) in Belgian hospitals were presented an online questionnaire checking for demographics, knowledge of and intention to work in 11 potential MCI disaster scenarios.

Results:

The Ebola outbreak, a train derailment with toxic release and the Paris / Brussels attacks raised national awareness which allowed us to score in 18 hospitals after the 7 hospital pilot. Ten more are ready to join giving a nationwide coverage.

Preliminary results reveal an overall highest response rate in the physician group where more than 1/3 works unconditionally. The supportive services score second best (27%) followed by the nurses (22%) and administration (21%). Highest response rate in all groups is found in seasonal influenza epidemics (54% works unconditionally). Ebola has the lowest rate of unconditional response (13%). Incidents where people will not respond to work, even with the risk of losing their job, are Ebola and nuclear incidents (9.5% and 8.8% respectively).  Since the West African Ebola outbreak, there is a clear downwards trend in willingness to work in these circumstances.

The majority of personnel will work under conditions. Factors that convince people to respond are in order of importance: availability of appropriate personal protective equipment, free availability of preventive medication or antidotes, insurance that family is safe, regular feedback on the evolution of the incident, previous training and communication channels with the family.

Conclusion:

Hospital managers should be aware that just a part of their personnel would come to work unconditionally in case of a disaster. Local evaluation can help identifying promoting measures to maximize response.

Luc MORTELMANS (Antwerp, Belgium), Christel HENDRICKX, Marc SABBE
10:10 - 10:20 #7626 - OP034 A REFUGEE CAMP IN THE CENTER OF EUROPE: CLINICAL CHARACTERISTICS OF ASYLUM SEEKERS IN BRUSSELS IN SEPTEMBER 2015.
A REFUGEE CAMP IN THE CENTER OF EUROPE: CLINICAL CHARACTERISTICS OF ASYLUM SEEKERS IN BRUSSELS IN SEPTEMBER 2015.

Background and purpose

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighbouring countries led to the influx of many asylum-seekers in some European countries, including Belgium.

This study aims to document demographics of asylum-seekers arriving in a refugee camp in Brussels in September 2015 and to describe diagnoses and comorbidities of patients presenting to a Field Hospital.

The study hypothesis is that among asylum-seekers in a huddled refugee camp – even in a well-developed country with all medical facilities – respiratory, digestive and other medical problems typical of refugee camps wherever in the world, will emerge soon.

Patients and methods

Using a cross-sectional observational study design, physicians of Médecins du Monde prospectively registered age, gender, origin, medical complaints and diagnoses of all patients presenting to an erected Field Hospital in Brussels in September 2015. Diagnoses were post-hoc categorised according to the International Classification of Diseases. Of 4037 patients examined, 3907 were included and analysed for this study: 86% were male, median age was 28 years (range 0-93;IQR 12), and patients came from 63 different countries, mostly from Iraq (52%), Syria (20%), Morocco (10%), Afghanistan (3%), and Palestine (3%). Some 1% were stateless.

Results

The most common primary diagnoses were upper respiratory tract infections (31%), dental caries (8%), skin infections (8%), gastroenteritis (7%), skin wounds and burns (6%), musculoskeletal disorders (6%), and accidental trauma (6%). Mental disorders were present in 2%. One per cent was victim of intentional violence in the country of origin, or during the journey to Brussels. Two women had just delivered and five new-born babies attended, of which one had to be hospitalised for bronchiolitis with severe dyspnoea.

When classified, the most frequent diagnosis categories were respiratory disorders (36%), far ahead of injury (12%), dental (10%), skin (9%), digestive (8%), and musculoskeletal diagnoses (6%).

Comorbidities consisted mainly of arterial hypertension and diabetes. Referrals were organised for 11% patients to dentists (5%), to Emergency Departments (3%), to psychotherapists (2%), and to new-born care (1%).

Features of infection were found in 49% of patients, with an even higher proportion (63%) in children younger than 5. A multiple logistic regression analysis indicates that the risk of being infected is significantly higher for asylum-seekers from Syria and Iraq, and for children.

Conclusions

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from respiratory, dental, skin and digestive diseases, and one of seven is injured. Half of this population shows features of infection; with asylum-seekers from Syria and Iraq, and children being most vulnerable, urging even developed countries to take measures to prevent the spread of infections. Early shelter, overcrowding reduction, adequate sanitary facilities, and accessible healthcare may avoid short and long term complications, leading to higher healthcare expenditure for the hosting population.

These findings should be anticipated when composing Emergency Medical Teams and Interagency Emergency Health Kits to be used in a Field Hospital, even in a Western European country.

Dr Gerlant VAN BERLAER (Brussels - BELGIUM, Belgium), Francisca BOHLE CARBONELL, Sofie MANANTSOA, Xavier DE BÉTHUNE, Ronald BUYL, Michel DEBACKER, Ives HUBLOUE
10:20 - 10:30 #7632 - OP035 COMORBIDITIES AND DIAGNOSES IN NORTHERN SYRIAN CHILDREN AFTER FOUR YEARS OF CIVIL WAR.
OP035 COMORBIDITIES AND DIAGNOSES IN NORTHERN SYRIAN CHILDREN AFTER FOUR YEARS OF CIVIL WAR.

Background and purpose

The civil war that started in Syria since 2011, led to one of the most complex humanitarian emergencies in history. This ongoing disaster, in which warring parties deliberately target healthcare infrastructure and services, has detrimental consequences affecting the health of children as one of the most vulnerable populations.

The purpose of this study is to document the medical threats, comorbidities, diagnoses and disease categories in Syrian children after four years of conflict, and estimate the need for relief efforts needed to provide efficient medical care to Syrian children.

Patients and Methods

A cross sectional observational sample study was conducted in May 2015. By means of a prospectively designed medical registry, Qatar Red Crescent healthcare workers especially trained for this study, collected demographic information, comorbidities, and diagnoses in children visited home by home and in internally displaced persons camps in four Syrian governorates. Diagnoses were post-hoc categorised according to the ICD-10 classification.

Of 1080 filled-out records, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

Results

Most primary acute diagnoses in examined children were upper respiratory tract infections (14%), lower respiratory tract infections (9%), gastroenteritis (8%), suspected meningitis (7%), asthma (6%), convulsions (6%), eye infection (5%), clinical anaemia (5%), and skin infection (5%). Four per cent showed signs of malnutrition, some children had been victim of injury (3%) or violence (1%), and 2% of children suffered from a mental disorder.

When categorised according to ICD-10, most children suffered from respiratory (29%), neurological (19%), digestive (17%), eye (5%) or skin (5%) diseases, 4% was injured, and 2% suffered from a mental disorder. Overall, 55% of patients had features of infectious diseases.

Most common chronical illnesses were mental health diseases (25%), epilepsy (11%), malnutrition related conditions (5%), and flaccid paralysis (4%).

Statistical analysis indicates that the risk for children to suffer from infectious diseases is significantly higher when they reside in Aleppo or Idleb. The risk of being injured is significantly higher in Aleppo, while intentional violence is most occurring in Lattakia. Mental problems are more prominent in Hamah. These problems are not linked to gender or age, except for infectious risks: younger children are more at risk to have an incomplete vaccination state, and suffer more from preventable dangerous infections.

Conclusions

After years of civil war, more than half the children in Northern Syria suffer from infections, mostly from respiratory, neurological and digestive origin, while 4% is injured or victim of dirty weapons.

Substandard paediatric healthcare circumstances and worsening vaccination state put Syrian children at risk for serious infections, outbreaks and morbidity, and should be urgently addressed by humanitarian relief efforts.

An immediate coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of health threats for children in Syria.

Dr Gerlant VAN BERLAER (Brussels - BELGIUM, Belgium), Abdallah Mohamed ELSAFTI, Mohamed AL-SAFADI, Michel DEBACKER, Ronald BUYL, Atef REDWAN, Ives HUBLOUE
10:30 - 10:40 #7635 - OP036 CHILDREN IN THE SYRIAN CIVIL WAR: IMPACT OF ON-GOING VIOLENCE ON THEIR SOCIAL, EDUCATIONAL AND PUBLIC HEALTH STATE.
CHILDREN IN THE SYRIAN CIVIL WAR: IMPACT OF ON-GOING VIOLENCE ON THEIR SOCIAL, EDUCATIONAL AND PUBLIC HEALTH STATE.

BACKGROUND AND PURPOSE

The Syrian civil war since 2011 led to one of the most complex humanitarian emergencies in history. This protracted disaster has but negative aspects, especially on children.

Purpose of this study is to document the impact on the social, educational and public health state of Syrian children.

 

PATIENTS AND METHODS

A cross sectional observational sample study was conducted in May 2015. Healthcare workers, especially trained for this study, visited families home by home with a prospectively designed questionnaire in four Northern Syrian governorates.

Of 1080 filled-out questionnaires, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

 

RESULTS

Almost 20% of children were Internally Displaced Persons. The father was deceased or missing in respectively 5% and 4%, and similarly for the mother in 2% and 3% of the children. Almost 15% had no access to safe drinking water, and 23% could not access appropriate sanitation. About 16% had insufficient access to nutrition, and almost 27% suffered from malnutrition. Access to specific mother and child healthcare providers was disturbed in 64%, and vaccination state was inadequate in 72%. More than half of all school-aged children had no access to education at the time of the study.

Statistical analysis indicates that the risk for children to have unmet depends mainly on the governorate in which they reside. Most affected governorates are Idleb and Lattakia for water, sanitation, education, and healthcare; and Aleppo for missing vaccines. These problems are not linked to gender or age, except for the vaccination state: the smaller the children, the more they are at risk to have an incomplete vaccination state.

 

CONCLUSIONS

After four years of civil war in Syria, many children have lost their parents, are being displaced, and live in substandard life quality circumstances. Most children miss education, undermining their own future and that of the country. Limited access to water, sanitation, and to regular and healthy food, together with increasing malnutrition rates, worsening of the immunisation state and accessibility to specific healthcare facilities add up to the factors that put Syrian children at risk for increased morbidity and mortality.

Urgent coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of social, educational and public health threats for children in Syria.

Abdallah ELSAFTI ELSAEIDY, M.D., M.SC (Egypt, Qatar), Garlant GERLANT VAN BERLAER, M.D., M.SC, Mohammad AL SAFADI, M.D., Michel DEBACKER, M.D., Ronald BUYL, PH.D., Atef REDWAN, M.D., PH.D., Ives HUBLOUE, M.D., PH.D.
Room OP-SCHATZKAMMERSAAL

Monday 03 October

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SIMWARS
09:10 - 17:40

SimWars 2016

Animators: Alessandro COSTA (Romentino, Italy), Lukas DRABAUER (Austria), Dr Abdo KHOURY (Senior attending Physician) (Besançon, France), François LECOMTE (PH) (Paris, France), Felix LORANG (Consultant) (Jena, Germany), Thomas PLAPPERT (Fulda, Germany)
Room M5-Maria-Theresien-App. I
10:45

Monday 03 October

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PH2-S1
10:45 - 11:05

Poster Highlight Session 2 - Screen 1

10:45 - 10:50 #7826 - Angioplasty reporting channels for acute coronary syndromes with ST segment (STEMI) within 24 hours.
Angioplasty reporting channels for acute coronary syndromes with ST segment (STEMI) within 24 hours.

Introduction: Regional health care agencies' preventive campaigns are urging patients and healthworkers to call the 112 prehospital Emergency Medical Services centre for any suspicious chest pain. In the event of a STEMI, access to a technical platform for angioplasty within 24 hours is recommended by the European Society of Cardiology, regulated by the prehospital Emergency Medical Services through optimal primary patient handling, or a secondary transfer. Some STEMI do not seem to benefit from this system.

Objective: Changes in the proportions of patients in each of these channels.

Methods: Comparative study of two interdepartmental observational prospective registers, for prehospital handling and interventional cardiology, including those STEMI undergoing an angioplasty within 24 hours between 2003 and 2014.

Evaluation criterion: Changes in the percentage of patients not benefitting from the prehospital Emergency Medical Services arrangements.

Results: For 11 years in the region, 46,303 STEMI patients have received angioplasty within 24 hours, 55% of which (25,850) were dealt with by the prehospital Emergency Medical Services ; 43% in primary care (19,965) and 12.7% in secondary care  (5,885). On average, each year 1,704 (± 212) STEMI were not dealt cared for.

Discussion: The number of STEMI not benefitting from the prehospital Emergency Medical Services is significant, even if it tends to decline. There is an urgent need to identify and learn more about the epidemiological characteristics of these patients, so they can benefit from more efficient care.

Hugues LEFORT, Alexandre ALLONNEAU (Paris), Olivier YAVARI-SARTAKHTI, Hakim BENAMER, Aurélie LOYEAU, Lionel LAMHAUT, Sophie BATAILLE, Frédéric LAPOSTOLLE, Christophe CAUSSIN, Gaëtan KARILLON, Christian SPAULDING, Yves LAMBERT
10:50 - 10:55 #8019 - The impact of meterological events on ST segment elevation myocardial infarction.
The impact of meterological events on ST segment elevation myocardial infarction.

As an important source of morbidity and mortality, ST segment elevation myocardial infarction is known to occur on the basis of certain risk factors including diabetes, hypertension, hyperlipidemia, smoking, and family history. In addition to these traditional risk factors, cocaine use, physical or emotional stress, traffic, and air pollution have also been shown to be triggers of myocardial infarction in some occasions. In the present study we aimed to investigate the impact of certain meteorological and air pollution parameters on ST segment elevation myocardial infarction (STEMI).

We conducted the present study in a retrospective manner after obtaining ethics committee approval. We included patients who were diagnosed with STEMI after being presented to our emergency department with symptoms suggestive of acute coronary syndrome between April 2011 and December 2015.  We obtained demographic and medical data including age, sex, risk factors, and co morbid conditions with the help of the patient information management system of our hospital. We obtained certain meteorological data of Ankara province pertaining to the study period, including maximum-minimum and average air temperature (°C), humidity (%), sea level pressure (hPa), and precipitation type and status (rain, snow, fog, storm, hail). We also accessed air pollution surveillance data (Particulate matter 2.5 and 10 (PM2.5 and PM10), Sulphur dioxide (SO2), Nitric oxide (NO), Nitrogen dioxide (NO2), Nitrogen oxide (NOx), Carbon monoxide (CO)).

The normality of distribution of continuous variables was tested by Kolmogorov-Smirnov test. Mann-Whitney U test was used for comparison of two independent groups of variables with a non normal distribution and Chi-square test was used to assess relation between categorical variables. Generalized additive regression models were built to investigate effects of main and lag effects of meteorological variables on STEMI. Lag effect analyses and models were constructed.  A p value < 0.05 was accepted as statistically significant. 

During a period of 1709 days, a total of 246 STEMI cases were presented to our emergency department. Males constituted 80.1% (n=197) of the cases and females 19.9% (n=49). The mean age of the study subjects was 58.58 ± 12.61 years. STEMI cases presented at 220 (12.9%) of 1709 study days.

We did not detect any significant difference between weather conditions during days with and without STEMI presentation (p>0.005). Weather events (rain, snow, fog, storm, hail) were not significantly correlated to STEMI events (p>0.005).

According to a 4-day lag analysis to determine the effect of variables related to weather condition on STEMI occurrence, there were no significant differences with respect to maximum, average, minimum temperatures, as well as in air pressure. On the other hand, minimum humidity was significantly correlated to STEMI presentations (Odds Ratio (OR) [95% Confidence Interval (CI)]=0,986 [0,972-0,999], p=0,036). Among air pollution parameters, on the other hand, only nitric oxide ((OR)[95%CI]=0,992 [0,987-0,998], p=0,006) and nitrogen oxide ((OR)[95%CI]=0,994 [0,990-0,999] p=0,010) were significantly correlated to STEMI presentation in Lag 2 analysis.

In conclusion, weather events were not correlated to STEMI presentation whereas minimum humidity, nitric oxide, and nitrogen oxide were significantly correlated to STEMI presentations in Lag 2 analysis. 

Afsin Emre KAYIPMAZ (Ankara, Turkey), Orcun CIFTCI, Cemil KAVALCI
10:55 - 11:00 #8041 - Role of Emergency Physicians in the treatment of cardiovascular emergencies.
Role of Emergency Physicians in the treatment of cardiovascular emergencies.

Background

Emergency Medicine (EM) as an independent specialty was established in Finland in 2013. In our country, EM is a specialty with a full-length training of six years (1). During the first years, more than 140 physicians have begun the specialization program led by the universities. For now, the work distribution between physicians working on call in “old specialties” and in EM in Emergency Departments (ED) is in transition. In this observational study we discuss on the widening role of Emergency Physicians (EP) in the treatment of cardiovascular emergencies in Kanta-Häme Central Hospital (KHCH).

 

Methods

Specialist training of emergency medicine in Finland follows the European Curriculum and it includes a large variety of treatments and procedures previously performed only by physicians of traditional specialities (1). Training the skills in anaesthesiology, cardiology, neurology and radiology enables several cardiovascular emergent procedures (2, 3). In a hospital, where all specialties are not available in emergency department 24/7, these can be done effectively, safely and without delay.In this study, we analysed the role of EPs in the treatment of three time-critical cardiovascular emergencies, namely acute ischaemic stroke (AIS), paroxysmal atrial fibrillation (AF) and deep vein thrombosis (DVT). In a long run we are going to study, whether EPs in charge might expedite the work process compared to traditional work distribution.

 

Results

According to our first results in AIS, the door-to-needle time (DNT) was shortened from 54 to 20 minutes after the transition period. Secondly, after a 6-month training period, we have shifted the main responsibility of AF cardioversion to EPs in May 2016. Thirdly, we have deepened the training of DVT ultrasound, which is going to be a normal working process in the beginning of January 2017. We continue to analyse the stability of our DNT results. Furthermore, the time intervals of two latter processes in the ED will be analysed rigorously. It is important to implement fluent treatment protocols for most common emergencies, in order to give treatment more effectively, saving time and resource simultaneously.

Conclusions

Cardiovascular procedures can safely be done by EPs to save both resources and time.

 

References

  1. Naskali J, Palomäki A, Harjola V-P, Hällberg V, Innamaa T, Rautava V-P. Emergency Medicine in Finland: First Year Experiences of Specialist Training. J Acad Emerg Med. 2014; 13: 26-9.

  2. Heikkilä I, Kuusisto H, Stolberg H, Palomäki A. Stroke thrombolysis given by emergency physicians cuts in-hospital delays significantly immediately after implementing a new treatment protocol. Scand J Trauma Resusc Emerg Med. 2016 24:46.

  3. Adhikari S, Raio C, Morrison D, Tsung J, Leech S, Meer J, Lyon M, Lopez F, Akhtar S. Do emergency ultrasound fellowship programs impact emergency medicine residents' ultrasound education? J Ultrasound Med 2014;33:999-1004.

Ville HÄLLBERG, Teemu KOIVISTOINEN, Ari PALOMÄKI, Ville HÄLLBERG (Hämeenlinna, Finland)
11:00 - 11:05 #7396 - The impact of adrenaline on haemodynamics during experimental cardiac arrest.
The impact of adrenaline on haemodynamics during experimental cardiac arrest.

Introduction: Out-of-hospital cardiac arrest is a critical condition. Despite of providing sophisticated pre-hospital therapeutic strategy, return of spontaneous circulation (ROSC) is reached at only 30-40%. It has been demonstrated that coronary perfusion pressure (CoPP) higher than 15 mm Hg is associated with increased chance of ROSC. For that purpose, intravenous administration of 1 mg of adrenaline every 3-5 minutes during advanced life support has been recommended. However, there has not been published any clinical study demonstrating a clear outcome benefit associated with this approach and the role of adrenaline during advanced life support is questioned. Therefore, we performed an experimental study to investigate intra-arrest haemodynamic effect of adrenaline in a porcine model of ventricular fibrillation.

Methods: After preparation, cardiac arrest with ventricular fibrillation was induced in 14 female domestic pigs. After 2 minutes of untreated cardiac arrest, mechanical cardiac compressions were delivered for 3 minutes and cardiac compressions with mechanical ventilation for further 10 minutes. Then, a defibrillation shock was delivered to reach ROSC and experimental animals were monitored for 20 minutes. Prior to cardiac arrest induction, the animals were randomly assigned to receive either 15 μg/kg of adrenaline intravenously fifth and tenth minute of cardiac arrest (group A, 7 animals) or to undergo life support without administration of adrenaline (group B, 7 animals). Besides of usual vital signs, invasive arterial blood pressure, central venous pressure, intracranial pressure (ICP) and end tidal CO2 were monitored. CoPP and cerebral perfusion pressure (CPP) were calculated.

Results: While ROSC was reached in all 7 group A animals, in group B only in 5 experimental animals (p=0.127). CoPP and CPP values were comparable at the baseline and during the first 5 minutes of cardiac arrest. Each adrenaline administration induced an increase of CoPP in group A when compared with group B (6th minute: 30.6±6.4 vs. 14.3±3.2 mm Hg; 11th minute: 29.4±8.5 vs. 12.3±2.4 mm Hg, p<0.001) followed by a subsequent decrease to group B values in the end of adrenaline dosing interval. Moreover, we observed a similar pattern of significant CPP increase in group A, whereas ICP values exhibited no difference from the group B animals. Adrenaline administration was associated with significantly higher EtCO2 values throughout the protocol (p<0.005).

Conclusions: Regular adrenaline administration led to a significant increase of CoPP, CPP and EtCO2 in our model of experimental cardiac arrest. This resulted in a higher chance of achieving ROSC. Adrenaline did not induced unfavourable increase of ICP values. The results support routine clinical use of adrenaline with a strong emphasis on compliance with distinct intervals of its administration, rather 3-4 minutes than 5.

Roman SKULEC (Kladno, Czech Republic), Anatolij TRUHLAR, David ASTAPENKO, Vladimir CERNY

Monday 03 October

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PH2-S2
10:45 - 11:05

Poster Highlight Session 2 - Screen 2

10:45 - 10:50 #7184 - How Can Primary Care Clinics and Urgent Care Clinics Aid Hospital Emergency Departments in the Treatment of Patients during a Disaster?
How Can Primary Care Clinics and Urgent Care Clinics Aid Hospital Emergency Departments in the Treatment of Patients during a Disaster?

Background:In the case of a disaster, there is an increased need to provide care to disaster victims. One of the challenges is the lack of resources, or diverting of resources, to manage the most serious cases. However, there is still a need to provide care for other patients with minor injuries, whose care might be delayed. The commonly used START triage tool was found to have sensitivity of 45.8 (95%CI, 36.7%–55.2%) for casualties that are triaged as green.

Goal: The purpose of the study is to develop and test a triage tool used to divert some of the patients from the scene of the disaster directly to primary care offices and urgent care centers.

The primary outcome of the study was the sensitivity and specificity of the triage tool. The secondary goal is to analyze if there is a significant difference in sensitivity and specificity when tool is used by paramedics vs. physicians.

Methodology: This was a two-step study. In the Derivation Phase, the Primary Care Assessment Triage Tool (PCATT) was developed by a focus group of family physicians. Neither the authors of this study nor the focus group participants had any knowledge of the subsequent validation cases during the derivation phase.

In the Validation Phase, cases were extrapolated from the charts of known patients, who were the victims of a Bus vs. Train accident in Ottawa, Canada. Cases were considered to be suitable for management in primary care offices if they required no procedures or hospital admission. We looked into eleven casualties that presented to the Queensway Carleton Emergency Department Ottawa, Canada, after the Bus versus Train accident that happened on September 18, 2013 in Ottawa, Ontario, Canada.  On the basis of these charts, test cases were created and distributed to paramedics and physicians.

Results:   In total 245 respondents began the questionnaire, and 212 completed the full 11 cases.  This included 151 physicians and 69 paramedics.  Overall sensitivity of the PCATT tool was 92.1% with 95% confidence interval 90% to 94%. Overall specificity of the PCATT tool was 56.7% with 95% confidence interval of 54% to 59%.When the PCATT tool was used by physicians, sensitivity was 94.1% and when used by paramedics, sensitivity was 87.9%. This was statistically significant (p=0.029) for confidence interval for effect size of 0.67% to 11%.Specificity was 58.5% for physicians and 53.1% for the paramedics. This was also statistically significant (p=0.038) for confidence interval for effect size of 0.38% to 12%.

Conclusion: In the case of our sample Mass Casualty Incident, the PCATT tool had a reasonable sensitivity when compared to other commonly used tools in the Emergency Department, although further study is clearly necessary. This tool appears to be to have reasonable sensitivity to be used to divert casualties with minor injuries and psychosocial need to the care of the primary care physicians and thus relieve the burden on already stretched resources in the emergency departments.

Svetlana CAKAREVIC (Ottawa, Canada), Jeffrey Michael FRANC
10:50 - 10:55 #7804 - Ethical treatment of the mangled extremity in a disaster: just-in-time education is not a curriculum.
Ethical treatment of the mangled extremity in a disaster: just-in-time education is not a curriculum.

Across the globe, volunteer disaster response teams may present to authorities to respond in the field to assist in a disaster. Though physicians on these teams may or may not have had rudimentary exposure to hospital amputations in their training, amputations may not be in their typical practice nor are they credentialed to perform amputations and they not aware of the indications, ethics and psychological effects of field amputations in a resource constrained, austere environment (RCAE) disaster setting.

Proper patient selection using an evidence based scientific consensus approach to arrive at an ethical decision to amputate or not, should be considered as important as proper procedural technique. Remarkably, there has been no tangible effort to incorporate this into a formal education of pre-hospital, trauma and emergency physicians.

An interactive website, www.JITFIELDAMP.com, was created that randomly assigned Emergency Physicians, recruited as likely first responding local Disaster Response Team or Foreign Medical Team physicians, into two arms: non-podcast or podcast. There were no demographic differences between the two arms. The non-podcast arm of 38 participants responded to a 10-question quiz of patients with a mangled extremity in a RCAE scenario, asking: “When would you amputate”. There were 5 answers on a scale, depending on the scenario, with eight scenarios describing an entrapped or mangled extremity with answers “now-3 time intervals-wait or never”, and two scenarios describing a crushed extremity with answers “now-2 time intervals, perform fasciotomy or never”.  The 33 participants in the podcast arm watched a 15- minute podcast explaining the ethical treatment indications of the mangled extremity in a RCAE then responded to the same quiz. The podcast was based on exhaustive review of the worldwide literature on the subject.

A panel of twelve physicians that have written extensively on the subject was created to determine inter-rater reliability of the 10-question quiz using the Fleiss method for multiple raters. The Kappa value was 0.06, which indicates only slight agreement between the raters.

Using the Welch Two Sample t-test, the mean quiz score for the control group was 4.7/10, while the mean score for the podcast group was 5.2/10. The confidence interval had a 95% certainty that the podcast improved the overall score by less than 1.5/10 (15%).

An expert panel was created to determine the validity of the questions, their lack of agreement can be explained by the lack of evidence-based consensus guidelines used to create a curriculum to teach the ethical treatment of the entrapped and the mangled extremity in a RCAE. Without a “gold standard’ to reference when designing questions of any quiz, the expected quiz results cannot be expected to be consistent.

Just-in-time education is not a curriculum. The dynamic environment of a disaster presents far too many ethical, assessment and treatment decisions to be taught in the constrained just-in-time format. Just-in-time education can be utilized to reinforce a specific widely accepted topic with few variables first taught in medical school or residency.

Eric WEINSTEIN, Lisa KURLAND, Ahmadreza DJALALI, Jeffrey FRANC, Brielle WEINSTEIN (Tampa, USA), Panna CODNER, Edward NORCROSS
10:55 - 11:00 #7817 - Evaluating the access to health of the post-conflict internally displaced persons of Granizal, Colombia.
Evaluating the access to health of the post-conflict internally displaced persons of Granizal, Colombia.

Study Objectives Unlike refugees, internally displaced persons (IDPs) are not granted a status that allows them explicit or specific international protection or assistance. After Syria, Colombia has the second largest population of IDPs in the world, estimated at 6.5 million. During Colombia’s prolonged internal conflict, large numbers were displaced from rural to peri-urban informal settlements.  The cities of Medellin, the second largest city in Colombia, and Bello are home to about 365,000 IDPs. Our objective was to provide the first description of factors that obstruct the utilization of medical services by this post-conflict displaced population.

Methods A descriptive, semi-structured qualitative study was conducted using open-ended group interviews in February 2016 by investigators at Harvard University and University of Utah. They were carried out in Granizal, Colombia, a community with a high concentration of IDPs, which straddles the municipalities of Medellin and Bello. Participants included IDP community leaders, key informants of NGOs providing healthcare and services to IDPs, and local experts in the field from the Universidad de Antioquia (N=12). Interviews were arranged in collaboration with faculty from the Universidad de Antioquia and conducted in Spanish. Thematic topics included current access to medical care, barriers to healthcare, and common disease burdens. They were subsequently transcribed into English. An inductive approach to data analysis was used to identify factors that obstruct the access to health for IDPs.

Results Due to social stressors and on-going violence, an IDP population of Granizal currently resides illegally in privately owned land. This fact does not allow them the protection or access to public services from Medellin or Bello. Without legal recognition by local governments, they lack access to potable water, electricity, public education, and medical services. This leads to high rates of diarrheal illness for children, poor quality of maternal health, and untreated chronic non-communicable diseases. A deficiency in concrete demographic and qualitative descriptive data is the principal barrier that prevents this IDP population from claiming additional protections from local governments.

Conclusion Although IDPs do not lose the rights afforded to those nondisplaced under national or international law, they do not have additional civil and economic protections and assistance created by their needs and vulnerabilities. The lack of recognition by the governments of Medellin and Bello leads to major public health challenges for this IDP population. We propose creating a large-scale descriptive qualitative survey that will provide the data necessary to improve access to health for this vulnerable population.

Nirma BUSTAMANTE, Casey GRADICK, Andres PATINO (Cambridge, USA), P. Gregg GREENOUGH, Christian ARBELAEZ
11:00 - 11:05 #7949 - Initial assessment and treatment of refugees in the Mediterranean Sea - A secondary data analysis concerning the initial assessment and treatment of 2656 refugees rescued from distress at sea in support of the EUNAVFOR MED relief mission of the EU.
Initial assessment and treatment of refugees in the Mediterranean Sea - A secondary data analysis concerning the initial assessment and treatment of 2656 refugees rescued from distress at sea in support of the EUNAVFOR MED relief mission of the EU.

Background

The flow of migrants from Africa/Middle East towards Europe via the Mediterranean has led to the need for an extensive European Union humanitarian support mission (EUNAVFOR MED)1,2. Germany is participating in this mission with two Navy vessels. The key medical challenges have included the urgent initial assessment3,4 and treatment of hundreds of rescued persons in distress at sea per refugee boat. The crew of one of the frigate was staffed with an additional anesthesiologist and an additional surgeon. We analyzed the medical requirements of such rescue missions as well as the potential benefit of various additional monitoring devices in identifying sick refugees within the primary medical assessment process.

Material/Methods

Retrospective analysis of the data collected from May–September 2015 at a German Naval Force frigate within the primary medical assessment and treatment process of refugees rescued from distress at sea. (Ethics Commission University of Ulm, Germany No.:284/15). Descriptive statistics, univariate analysis as well as multivariate analyses were performed.

Results

A total of 2656 refugees had been rescued from 10 refugee boats. 77.1% were male, 0.7% infants, 10.3% children, 88.5% adults and 0.5% elder people. 16.9 % of them were classified as “medical treatment required”. 3.1% needed a treatment in the emergency field hospital. The demographic data as well as the health status were significantly different between the refugee boats.

In addition to the clinical assessment by a physician, PR, CBT and SpO2 were evaluated. Sick / injured refugees displayed a statistically significant higher PR (114/min vs. 107/min; p<0.001) and CBT (37.1°C vs. 36.7°C; p<0.001). There was no significant difference in SpO2-values. The same results were found for the subgroup of patients classified as “treatment at emergency hospital required”. However a much larger difference of the mean PR and CBT (35/min resp. 1.8°C) was found when examining the subgroups of the corresponding refugee boats. A cut-off value of clinical importance could not be found. Predominant diagnoses have been dermatological (55.4%), followed by internal diseases (cardiovascular 22.1%, pulmonary 4.5%, abdominal infection 1.1%) and surgical conditions (trauma 7.6%, orthopedic 4.5%). Infrequent conditions were ENT / OMS (1.8%), ophthalmological (1.8%) and gynecological problems (1.1%). One child was given birth on board the frigate. None of the refugees classified as “healthy” within the primary assessment process changed to “medical treatment required” during further observation.

Conclusions

Most of the refugees were male adults, and approximately 1/6 of them received initial care. 1/5 of them needed treatment at an improvised emergency field hospital. Aggravated preexisting conditions due to lack of hygiene or violence are the main causes. The initial assessment of people in distress at sea has proven effective if an experienced physician carries it out. PR, SPO2, and CBT were not suitable for distinguishing between healthy and sick / injured people.

References

1. Pfortmueller CA PLoS One 2013; 8: e82671

2. Ng C Scand J Trauma Resusc Emerg Med 2015; 23

3. Lidal IB Scand J Trauma Resusc Emerg Med 2013; 21: 28

4. Lerner EB Prehosp Emerg Care 2015; 19: 267-71

Martin KULLA (Ulm, Germany), Florent JOSSE, Bjoern HOSSFELD, Lorenz LAMPL, Helm MATTHIAS

Monday 03 October

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PH2-S3
10:45 - 11:05

Poster Highlight Session 2 - Screen 3

10:45 - 10:50 #7407 - Awareness of Emergency physicians to the Adverse Drug Reactions reporting: the effect of an Italian pharmacovigilance project.
Awareness of Emergency physicians to the Adverse Drug Reactions reporting: the effect of an Italian pharmacovigilance project.

Background

Voluntary reporting is a fundamental tool to increase knowledge about drug security and postmarketing surveillance. Several epidemiological studies show that a good percentage of Emergency Department (ED) visits are due to adverse drug reactions (ADRs). Nonetheless, under-reporting of these events is still frequent. Therefore, intervention is needed to educate ED physicians on a continuous pharmacovigilance activity.

Methods

A pharmacovigilance project has been initiated on September 2012 in  Sant’Andrea Hospital of Vercelli, Italy, involving both pharmacists and emergency doctors. In this study the reporting trend of ADRs in the ED has been evaluated from 2011 to 2015, and the effect of the project on clinical practice was considered. The project didn’t provide a training phase for the physicians before its onset.

Results

Vercelli Hospital is a secondary hospital in Piedmont region. The activity of ED can be considered as uniform from 2011 to 2015 regarding overall visits (average: 38378 patient per year), middle age (52,75 years), triage color average rate, in terms of clinical priority (red codes: 1,41%; yellow codes: 13%; green codes: 75,3%; white codes: 10,20%) and clinical problems distribution (traumatic pathologies average rate: 29,4%; non-traumatic pathologies average rate: 70,6%). The ADRs reporting in this five years interval was: 1 in 2011 (before the pharmacovigilance project), 14 in 2012, 132 in 2013, 172 in 2014, 263 in 2015.

Conclusions

At Vercelli hospital ED, considering an uniform population evaluated, the starting of a pharmacovigilance project, without a direct training for the physicians, has increased the awareness of ADRs reporting among them, with a progressive increase of the reports and a more careful attitude to consider drug interactions as a possible cause of signs and symptoms evaluated in ED. The collaboration between physicians and pharmacists has made the process much simpler.

Barbara GABRIELLI, Roberta MARINO (Vercelli, Italy), Federica CALDERA, Mariangela ESILIATO, Aldo TUA, Francesco Saverio MOSCHELLA, Roberto CORGNATI, Roberta PETRINO
10:50 - 10:55 #7603 - A blended team based learning initiative for a paediatric emergency medicine orientation programme.
A blended team based learning initiative for a paediatric emergency medicine orientation programme.

Background/ Introduction

Both Blended Learning and Team Based Learning (TBL) have roots in the constructivist theory, which emphasizes learners taking initiatives in learning. Individually, Blended Learning and TBL have been shown to be useful instructional methods but there has been little research done on the combination of the two. An orientation programme in paediatric emergency medicine was developed using a combination of the two (Blended TBL). This combination, allows collaborative work on real-life clinical problems, repetition, accountability, independent learning and indirect coaching by faculty, and is likely to play an important role in preparing doctors for actual work on the ground.

 

Participation and Methods

The programme is compulsory for all junior doctors who rotate through Emergency Medicine at KK Women’s and Children’s Hospital. The Blended TBL programme comprises e-learning modules that have to be completed over a period of 3 weeks and three, weekly, face to face TBL sessions with faculty.  The online modules include patient vignettes and clinical scenarios, quizzes, real time feedback to questions, web-links, self-assessment and multimedia such as videos and audio recordings to improve learner engagement. The TBL component comprises pre-class preparation via the online modules, readiness assurance tests and application exercises based on real life clinical scenarios. At the end of the programme, learner perceptions are assessed using the ETELM-LP (Evaluation of Technology Enhanced Learning Materials: Learner Perception) instrument that collects both qualitative and quantitative data.

 

Results

67 learners underwent the programme from November 2015 to April 2016. 94% of learners agreed or strongly agreed that the course was excellent, prepared them for work on the ground and promoted achievement of the course objectives. 91% found that the course would change their practice. The qualitative feedback revealed that the components that learners appreciated most were the multiple levels of interaction (21.3%), questions and clinical scenarios (20.4%), the relevance to real work (13.9%) and the collaborative group work (13.9%). Learners felt that the programme gave them the confidence to start work.

 

Conclusion

Blended Team Based learning may be a useful instructional method that combines the benefits of Blended Learning and TBL. The collaborative learning that takes place amongst peers, when real life problems are discussed and opportunities are given for reflection, may enhance learning and prepare doctors for clinical work. 

Arif TYEBALLY (Singapore, Singapore)
10:55 - 11:00 #7649 - A blended learning approach to implementing new guidelines in sepsis using the Medutainment concept.
A blended learning approach to implementing new guidelines in sepsis using the Medutainment concept.

Background: Implementing new guidelines and changing clinical practice is a challenge. In April 2015 the Surviving Sepsis Campaign (SSC) released new guidelines on the treatment of severe sepsis and septic shock. Many barriers related to implementing guidelines exist; these include lack of awareness and lack of dissemination. “Medutainment” is a concept that presents the curriculum in an entertaining way addressed at improving the learner’s motivation towards the subject. The concept incorporates elements from popular entertainment and combines it with the academic curriculum

 

Methods: The study was performed during a 7-day international summer school in emergency medicine with 60 attending medical students. The intervention was based on the flipped classroom model and contained five elements: online videos, a pocket guide, an interactive online game (“Who wants to be a Sepsionaire?”), a workshop (based on the “Jeopardy” television programme) and a simulation scenario. Post-course the participants evaluated the course through an online survey. Data from the online game was collected and used to quantify the students’ progress.

 

Results: The online game had a total of 273 entries. The average of points attained increased with 106 points out of 1484 possible points from the first to the final attempt on the game. The amount of correct answers was improved by 7.6% and the answering time was reduced from 3.22 to 1.33 minutes. A total of 77% evaluated the method as being both useful and entertaining.

Conclusion: Using a blended learning model together with the “Medutainment” concept increased the time students spent on preparation and increased their self-assessed abilities in diagnosing and treating sepsis. 

Mathias GELDERMANN HOLGERSEN, Theo Walther JENSEN (Copenhagen, Denmark), Sandra VIGGERS, Anders GRANHOLM, Mads SEIT JESPERSEN
11:00 - 11:05 #7833 - USING HIGH-FIDELITY SIMULATION FOR POST GRADUATE YEAR STUDENTS IN EMERGENCY MEDICINEDEPARTMENT.
USING HIGH-FIDELITY SIMULATION FOR POST GRADUATE YEAR STUDENTS IN EMERGENCY MEDICINEDEPARTMENT.

Objectives: Post Graduate Year(PGY) program is important for developing medical education in Taiwan. One-monthtraining in emergency medicine departement started compulsorily for every graduated medical student since July 2011.Since the characteristics of emergency patients are emergency, severe, difficult and troblesome, it is a extremely challenging for PGY student. The appropriate uses of simulation based training can enhance the teaching and learning for students in emergency medicine departement.

Methods: In 2014, we designed a training course using high-fidelity simulation for PGY students of emergency medicine traning. Trainees were divided into pairs and each pair participate one scenario. They assessed by standardized written tests before (Pre-test) and after the course (Post-test) after each simulation session. 82 PGY students of the emergency medicine department participated this training course between Oct 2014 and Dec. 2015.

Results: During Sep. 2014 to Dec. 2015, 82 PGY students participated this training course and 82 questionnaires were collected and analyzed using paired t-test (100%). The mean score of Self-Confidence in the pre-test is 2.8 and that in the post-test is 4.0 (p < 0.001). The mean score of Communication Skills in the pre-test is 3.0 and that in the post-test is 4.0 (p < 0.001). The mean score of Leadership in the pre-test is 3.1 and that in the post-test is 4.1 (p < 0.001). The mean score of Situation Monitor in the pre-test is 3.2 and that in the post-test is 4.2 (p < 0.001). The mean score of Mutual Support in the pre-test is 3.2 and that in the post-test is 4.3 (p < 0.001). The average of training course satisfaction is 4.9.

Conclusion: High-fidelity simulation provide a harmless, repetitive and effective environment. It can improve quality and ability of PGY students in critical care training education and will increase patient safety in health care. For further educational programs, we suggest high-fidelity simulation combined with clinical patient safety policies for all health-care providers to reduce the incidence of medical errors.

Pei-Yin LIU (Kaohsiung city, Taiwan, China), Li-Ping KE, Chu-Feng LIU, Chien-Hung WU

Monday 03 October

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PH2-S4
10:45 - 11:05

Poster Highlight Session 2 - Screen 4

10:45 - 10:50 #7008 - Relevance of imaging in case of dizziness in an urban ED.
Relevance of imaging in case of dizziness in an urban ED.

Introduction:

Dizziness is responsible for an estimated 1-2% of emergency department (ED) visits in France. Faced with various clinical presentations, physicians must distinguish between peripheral and central causes of dizziness. The aim of this study was to assess the relevance of imaging examinations in case of dizziness in a teaching hospital in France.

Methods:

We present here a retrospective and monocentric study that enrolled all patients from July 15 to November 15 (2015) in a teaching hospital. The target population was patients presenting with acute dizziness, nystagmus or balance problems.

Results:

One hundred seventy-four patients with dizziness were included for statistical analysis. The study population consisted of 32.2% men with an average age of 52 years (+/-14 years; ranging from 16 to 97 years). Based on clinical examination, we divided the patients into 3 groups: A) central lesion = 9 patients, B) benign peripheral vestibular disorders = 110 patients, and C) all other causes (hypotension, headache, hypoglycemia, intoxication) = 55 patients. 9 MRI (magnetic resonance imaging) were performed on group A and 6 strokes were found. 112 CT scans (computed tomography scan) without enhancement were performed on groups B (n=96) and C (n=16), without any acute pathological findings. A specialized consult was requested in 82% of cases (64% neurology and 18% ENT specialist). Group A consisted of 6 cases with vertebrobasilar stroke, 2 cases of newly diagnosed tumor and 1 case of multiple sclerosis. Group B had a diagnosis of benign paroxysmal positional vertigo in 100 cases, Meniere’s disease in 6 cases and vestibular neuritis in 4 cases. In group C, a diagnosis of hypotension was made in 3 cases, cervical pain in 3 cases, headache in 12 cases and hypoglycemia or discomfort in 42 cases.

Discussion:

In our study, the initial examination consisted of a full clinical examination (cardiovascular, respiratory, digestive), a vestibular examination (nystagmus, index deviation, Fukuda and Romberg’s tests) and a neurological examination (cranial nerves, muscular and sensitivity test, deep tendon reflexes, Babinski). Recent studies suggest that a complete bedside clinical examination combined with a benign result to HINTS (head impulse test, nystagmus, skew deviation) examination “rule out” stroke with an acceptable specificity (96%), which reduces the number of imaging test.

Conclusion:

Despite a clinical diagnosis of benign peripheral vestibular disorders, most physicians choose to perform an imaging test to exclude a more serious condition, mainly a stroke. Using the HINTS test combined with an ABCD2 score (age, blood pressure, clinical features, diabetes), could help ED physicians in their diagnostic process and reduce the number of imaging tests performed as well as patient radiation dose.

Elena Laura LEMAITRE, Pierrick LE BORGNE (Strasbourg), Charles-Eric LAVOIGNET, Sarah UGÉ, Céline RENFER, Hakim SLIMANI, Claire KAM, Pascal BILBAULT
10:50 - 10:55 #7290 - Accuracy and reliability of ultrasound for detecting stomach contents.
Accuracy and reliability of ultrasound for detecting stomach contents.

Background

Identification of stomach content by point-of-care ultrasound can help determine risk of aspiration prior to procedural sedation or intubation. We sought to determine the test performance characteristics and agreement of emergency physician interpretation of gastric ultrasound.

 

Methods

We performed gastric ultrasound of healthy volunteers randomized to fast for at least 8 hours, or to consume carbohydrates and water. Images of the stomach were obtained using each of the subxiphoid, left upper quadrant, and right lateral decubitus windows. Two emergency physicians with fellowship training in emergency ultrasound, but limited experience with gastric ultrasound, independently reviewed all the examinations. They recorded their interpretation for each window as stomach content present or absent, or stomach not visualized. Test performance characteristics for each sonologist and inter-rater agreement were calculated.

 

Results

45 gastric ultrasounds were performed. For each of the sonographic windows, the sonologists detected stomach contents with high sensitivity, ranging from 89 – 100% (95% CI 71 – 100%). Sonologist specificity for stomach content was highest using the subxiphoid view (59%; 95% CI 34 – 80%), and lowest in the left upper quadrant window (13%; 95% CI 1 – 53%). Overall inter-rater agreement between the sonologists was good (kappa 0.64; 95% CI 0.5 - 0.78).  Agreement was very good using the right lateral decubitus (kappa 0.91; 95% CI 0.74 - 1) and subxiphoid (kappa 0.72; 95% CI 0.51 – 0.94) approaches but only fair for the left upper quadrant window (kappa 0.4; 95% CI 0.1 - 0.67).

 

Conclusion

Emergency physician sonologists were sensitive but not specific at detecting stomach contents. Sensitivity of the subxiphoid, left upper quadrant, and right lateral decubitus windows were similar. Image interpretation agreement between emergency physicians was very good for the subxiphoid and right lateral decubitus approaches. Gastric ultrasound may be interpreted more readily and accurately using these windows.

 

References

Perlas A, Davis L, Khan M, Mitsakakis N, Chan VW. Gastric sonography in the fasted surgical patient: a prospective descriptive study. Anesth Analg 2011. 113:93-7.

Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anesth 2014. 113:12-22.

Acknowledgments

No funding source to report or conflicts of interest to disclose.

David MACKENZIE (Portland, USA), Aftab AZAD, Vicki NOBLE, Andrew LITEPLO
10:55 - 11:00 #7424 - Up to 2/3 of qualified ultrasound exams in the ed provides therapy relevant information.
Up to 2/3 of qualified ultrasound exams in the ed provides therapy relevant information.

Background:
Emergency ultrasound is an important tool in the ED, which is already highly integrated in the daily work in our Emergency Room. However, not much data is available concerning the number, the quality and the relevance of those ultrasounds in regard to decisions about patients therapy. In our opinion especially the last part is extremely important as it directly affects the treatment. To this day there is to our knowledge no data on the influence on decision making in Emergency Ultrasound available. We suspect that Information obtained by Ultrasound is significantly influencing therapy decisions as well as facilitates discharge from the ED  in case of a clean result. 

Methods:
During 2 Weeks all Ultrasound exams in the daytime (8:00-20:00) were collected and looked at. We made sure, that each exam was performed by an experienced doctors of our ED, all of them with at least 3 years of ED and proficient Ultrasound experience. Sufficient Experience was defined by the recommendations of the German society on Ultrasound. We could collect 96 exams in our time frame. We looked at the type of Ultrasound, the indication for the Exam, Therapy relevance defined as inducing further Diagnostics (e.g. CT) or Treatment (e.g. Surgery), a possible discharge due to an age appropriate normal Ultrasound exam and inconclusive Results.

Results:
Of the 88 exams we could identify 40 clinically relevant Exams in our results. Another 40 Patients could be safely discharged from our ED, none of whom had a second visit in the next 48h. In only 18 Patients the Ultrasound didn’t help in the decision making or didn’t bring any relevant results.

Conclusion:
High quality Ultrasound Exams are a valuable Tool in our ED. Based on the results we have strong evidence that in more then 2/3 of all cases at least in our ED and way more often than anticipated the results of our Ultrasound Exams are relevant and will clinically significantly influence the following treatment of the Patient. 

Felix LORANG (Jena, Germany)
11:00 - 11:05 #7728 - Multiple-rule out CT-screening of high-risk all cause patients in an emergency department.
Multiple-rule out CT-screening of high-risk all cause patients in an emergency department.

OBJECTIVE. To document the impact of screening with a multiple-rule out CT scan of high-risk patients presenting in an Emergency Department (ED).

BACKGROUND. Previous studies show that patients triaged as high risk (Red) or moderate-to-high risk (Orange) based on vital parameters, according to local triage algorithm (Danish Emergency Process Triage), have a high 30-day mortality rate (10-30%). For this group of patients, screening with a multiple-rule-out CT scan might be beneficial, but at the cost of radiation exposure and additional exams without diagnostic significance.

SUBJECTS AND METHODS. 100 patients were enrolled in this study. Patients triaged as Red or Orange on vital parameters using Danish Emergency Process Triage (DEPT) and 40 year or older were eligible for inclusion. Exclusion criteria included known kidney-disease (GFR<45), impaired cognitive function, circulatory unstable patients, patients with many previous CT-scans and patients where CT-scan would delay relevant acute treatment.

ER physicians filled out tentative diagnosis prior to the CT scan. Patients were scanned with an ECG-gated dual energy CT-scan of cerebrum, thorax and abdomen. The average radiation dose given was 16.3 mSv and all patients received 90 ml contrast. Results and findings of the scan were reported to ER physician by a radiologist immediately following the scan. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by 2 physicians separately. Any disputes were settled by a third party.

RESULTS. *(Preliminary results/final result available in October) Data from 88 patients [52% female, 71yrs (43-94)] was available. The treating physician would have ordered an acute CT-scan in 15 (17%) of the included patients, and these patients were excluded in the following analyses. For the remaining 73 patients  CT scan resulted in change in acute treatment for n=6 patients (8%). The scan resulted in further examinations for 7 patients (10%), of which 4 (60%) were diagnostically significant.  In 5 (7%) of the patients, CT- scan lead to diagnosis of previously undiagnosed malignant tumor. The scan disproved primary diagnosis for 7 (10%) of patients. The 30-day mortality of the included patients was 8% (5 of 65 patients). The results of the CT-scan were given within an hour for 73% of patients.

CONCLUSION. Based on our results, it is likely that a screening with a multiple-rule out CT scan of high-risk patients in an ER would result in discovery of additional diagnoses and malignant tumors, but at the cost of higher radiation exposure and additional exams without diagnostic significance. Larger randomized studies are needed to further evaluate the clinical impact of these findings.

Mia PRIES-HEJE (Vanloese, Denmark), Rasmus HASSELBALCH, Henriette RAASCHOU, Michel NÈMERY, Lisbet RAVN, Morten LIND, Thomas BOEL, Peter ULRIKSEN, Kasper IVERSEN

Monday 03 October

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PH2-S5
10:45 - 11:05

Poster Highlight Session 2 - Screen 5

10:45 - 10:50 #5030 - Management of acute pyelonephritis in the emergency room of the teaching hospital la rabta (tunisia).
Management of acute pyelonephritis in the emergency room of the teaching hospital la rabta (tunisia).

Background : The urinary tract infections and in particular the acute pyelonephritis occupy an important place in General Medicine and they generate an appreciable amount of antibiotic therapy, not always adapted as for the choice of antibiotics and for the duration of the treatment. The aim of our study was to assess the management of the acute pyelonephritis by the doctors exercising in the ER of the teaching hospital La Rabta, then to compare the results obtained with the new recommendations of La Société de pathologie infectieuse de langue française (SPILF).

Methods: It was about an analyticalcross-sectional study concerning 59 patients affected by acute pyelonephritis and consulting in the ER of the teaching hospital LaRabta during the period from February 2014 till July 2014.

Results: 59 patients were included in the study, 49 women and 10 men. The mean age of the patients was 48,9 years (19,5 to 87 years). The urinary tract dysfunctions and anomalies were noticed in 49,2% (n=29/59) of the patients. This was mainly tumors of the urinary tract (prostatic hypertrophy, renal cysts…) in 20,3% (n=12/59), a dilation of the urinary tract in 18,6% (n=11/59) and an urolithiasis in 15,3% (n=9/59). The risk factors of complication were noted in 57,6% (n=34/59) of our patients. It was especially about the diabetes noted in 37,3% (n=22/59), elderly people with comorbidity in 15,3% (n=9/59), a pregnancy in 10,2% (n=6/59) and a severe renal failure in 8,5% (n=5/59). A severe sepsis was found in 3,4% (n=2/59) of the patients of our sample. No case of toxic shock was observed. E. Coli was the bacteria isolated in 86,4% (n=51/59) of the cases. The wild type E. Coli was identified in 21,6% (n=11/51) of the patients with an E. Coli caused pyelonephritis. Extended-spectrum beta-lactamases (ESBLs) producing E. Coli was identified in 23,5% (n=12/51). The plain-film radiography was performed in 78% (n=46/59) of our sample’s cases. The renal ultrasonography was realized in 62,7% (n=37/59). A contrast-enhanced CT scan was performed in only 3,4% (n=2/59) of the patients. We decided the hospitalization for 42,4% (n=25/59) of the cases. This decision interested 59,5% (n=25/42) of the patients with a pyelonephritis at risk of complication. The empiric antibiotic therapy was begun in the ER in 79,7% (n=47/59) of the patients.  In 42,6% (n=20/47) of the patients who were initially treated in the ER, the empiric antibiotic therapy was incompatible with the last recommendations of the SPILF. In 46,2% (n=18/39) of the patients treated exclusively in the ER, duration of the antibiotic therapy was not in compliance with the new recommendations. The clinical evolution was favorable in all patients without any complication.

 

Conclusion: The management of acute pyelonephritis in the ER of the teaching hospital La Rabta presents some conflicts compared with the last recommendations of the SPILF, as regards especially the nature and the duration of the empiric antibiotic therapy. The implementation of a therapeutic protocol within the ER and the follow-up of the patient’s evolution will allow the optimization of this management.

Jobrane MANSOURI (Tunis, Tunisia)
10:50 - 10:55 #7101 - Intraosseously administered antibiotics in experimental septic shock.
Intraosseously administered antibiotics in experimental septic shock.

Background:

Intraosseous (IO) access is proven useful when vascular access is difficult to achieve. IO options apart from fluid administration are drug delivery, blood sampling, blood transfusion, injection of contrast dye as well as induction of hypothermia for cerebral protection after cardiac arrest and resuscitation.

However, it is not known whether antibiotics administered IO reach sufficient plasma levels during shock.

Thus, we designed an experiment in order to compare the plasma levels of two antibiotics commonly used in severe infections, i.e. gentamicin and cefotaxime, during experimental septic shock.

 

Animals and Methods:

Eight apparently healthy pigs were anesthetized. Arterial, central venous and pulmonary arterial catheters were inserted. An EZ-IO® (Teleflex Medical Europe, Athlone, Ireland) was introduced into the proximal tibia. The Animal Ethics Committee of Uppsala University, Sweden approved the experiment.

An infusion of endotoxin at 4 microg/kg/h was started to induce experimental septic shock. 75 mg/kg of cefotaxime and 7 mg/kg of gentamicin were randomly administered intravenously (IV) or IO at the onset of endotoxemic shock. Cefotaxime in plasma was determined by reversed-phase high-pressure liquid chromatography separation coupled to mass spectrometry. Gentamicin was analyzed on an Architect Ci8200 analyzer.

Venous samples were taken at 5, 15, 30, 60, 120 and 180 minutes from the pulmonary artery catheter.

Area under the curve (AUC; mg/h/L) was determined and the confidence interval for the ratio of means was computed. Values are given as median (range).

Results:

The endotoxin infusion induced expressed circulatory derangements. Both mean arterial pressure (MAP) and cardiac index were reduced, whereas mean pulmonary arterial pressure (MPAP) increased. Due to the reduced cardiac performance and increased right-sided filling pressure, seven out of the eight pigs received norepinephrine, which was administered at the investigators discretion, in order to keep MAP > 60 mm Hg and/or MAP > MPAP.

At 5 minutes after the IV and IO injections of cefotaxime, the plasma concentrations were 183 mg/mL (161 – 201) and 200 mg/mL (135 – 260), respectively. The corresponding values for gentamicin injected IV was 29.2 mg/mL (27.5 – 34.8) and when administered IO 34 mg/mL (28.8 – 38.2).

AUC for cefotaxime administered IV was 116.5 + 11.1 and when given IO it was 108.1 + 19.5. The kinetics of elimination for both antibiotics were similar regardless of injection site.

 

Conclusion:

Cefotaxime and gentamicin are commonly used in severe infections e.g. meningitis or septicemia. In septic shock, expressed circulatory derangement, is one of the clinical manifestations. When venous access is difficult to achieve, which may be the case in pediatric patients, especially in the pre-hospital setting, and rapid administration of antibiotics is urgent, the IO approach may be considered.

 

References:

Resuscitation 2010;81:1305-52

Resuscitation 2010; 81:1364-1388

Crit care med. 2006; 34:1589-96.

Crit Care Med. 2013 41:580-637.

Acta Anaesthesiol Scand. 2015 59:346-53

 

Acknowledgements:

 Dr Eriksson has also received a travel grant from Vidacare Corporation and Dr Michalek received payment for statistical assistance from the same company. Vidacare and Teleflex has financially supported our research.

Gunnar STRANDBERG, Anders LARSSON, Miklós LIPCSEY, Joel MICHALEK, Mats ERIKSSON (Uppsala, Sweden)
10:55 - 11:00 #7106 - Diagnostic value of presepsin for sepsis in the new definitions.
Diagnostic value of presepsin for sepsis in the new definitions.

Background: The third international consensus presented the new definitions for sepsis and septic shock, but there is little discussion about exactly how to determine whether infection is suspected. Presepsin is currently under investigation in clinical practice as a biomarker of bacterial infections.

Objective: The aim of this study was to investigate the diagnostic value of presepsin compared to other diagnostic makers of sepsis in the new definitions.

Methods: Ninety one patients with SOFA score of 2 or more were included. We divided patients into three groups based on their clinical features: non-sepsis group (n=29), sepsis group (n=29) and septic shock group (n=33). Blood samples for biomarker measurements of presepsin, procalcitonin (PCT), C reactive protein (CRP) and white blood cells (WBC) were collected at days 1, 3 and 7 after clinical onset of a SOFA score of 2 or more.

Results: Both PCT and presepsin concentrations were significantly higher in both sepsis and septic shock groups compared to non-sepsis group [PCT (median, ng/mL): 0.6 vs. 1.4 vs. 11.0、p<0.001; presepsin (median, pg/mL): 349 vs. 817 vs. 1217、p<0.001; non-sepsis vs. sepsis vs. septic shock group]. Since the area under the curves (AUC) of the presepsin to distinguish sepsis including septic shock or non-sepsis at day1 was 0.88, and significantly higher than that of PCT, CRP, or WBC, indicating that presepsin levels have valuable capacity to diagnose of sepsis or non-sepsis in the early phase. The cutoff value for presepsin was 508 pg/ml with the 87% sensitivity and 86% specificity. On the other hand, the cutoff value for PCT was 1.5 ng/ml, corresponding to 68% sensitivity and 86% specificity. In addition, the logistic regression analysis revealed that high presepsin levels (≥500 pg/ml) were significantly associated with diagnosis of sepsis (odds ratio: 68.89, 95% CI: 12.05- 393.98, p<0.001).

Conclusion: Presepsin is useful in diagnosis of whether sepsis or non-sepsis patients with 2 or more than SOFA points.

Tomonori YAMAMOTO (Shijyonawate, Japan), Yamamoto HIROMASA, Tetsuro Nishimura TETSURO, Shinyama NAOKI, Noda TOMOHIRO, Shinichiro KAGA, Takahumi TERADA, Kenichiro UCHIDA, Takasei MORIOKA, Hiroharu TAKESADA, Maiko ESAKI, Hoshi HIMURA, Yasumitsu MIZOBATA
11:00 - 11:05 #7561 - Early clinical reassessment in emergency department short stay units by emergency physicians helps to reduce antibiotic use in community-acquired pneumonia.
Early clinical reassessment in emergency department short stay units by emergency physicians helps to reduce antibiotic use in community-acquired pneumonia.

Background:  Community-acquired pneumonia (CAP) is a frequent reason for consulting with the healthcare system and is a leading infection-related cause of death in developed countries. The diagnosis of CAP is difficult, because of the limitations of clinical, radiological and biological examinations, leading to an overprescription of antibiotics. Several studies accessed the contribution of procalcitonin (PCT) with the development of an algorithm to guide initiation of the antibiotic treatment in CAP. Another strategy relies on an early clinical reassessment made in the first 24 hours of hospitalization to confirm the diagnosis of CAP and the need to maintain antibiotic treatment. To date, these two strategies have not been compared. Thus, the objective of our study was to compare these two strategies to reduce the duration of antibiotic treatment in CAP in a randomized clinical trial. Material/methods: Prospective, randomized and controlled trial including adult patients admitted in the ED with the main diagnosis of CAP. In the clinical reassessment group, antibiotic treatment was systematically started in the emergency department. A clinical reassessment was made during the first 24 hours of hospitalization in the ED short stay unit to reconsider the diagnosis of CAP, and to stop the antibiotherapy initiated in the emergency department if the diagnosis is not confirmed. In the PCT guided group, initiation and discontinuation of the antibiotherapy was based on the PCT cut-off ranges previously published. Results: In total, 286 patients were included in 10 hospitals in France and randomized in the clinical reassessment group or into the PCT guided group. In the clinical reassessment group, CAP diagnosis was reconsidered and antibiotic treatment was stopped in 8.9% of the patients. In the PCT guided group, antibiotic treatment was not started in 8.1% of the patients. The difference was not significant between the 2 groups. Globally, the antibiotic treatment duration was shorter in the clinical reassessment group when compared to the PCT guided group (8 days Vs 10 days, p<0.05). There was no difference in terms of success rate at day 30 between the 2 groups. Conclusions: Our study showed that an early clinical reassessment in ED short stay units is a safe strategy and can reduce antibiotic consumption in CAP.

Emmanuel MONTASSIER (Nantes), Fares MOUSTAFA, Albert TRINH-DUC, Maxime MAIGNAN, Caroline ANNOOT, Ogielska MAJA, Pascal Louis ORER, Jean Benoit HARDOUIN, Thibault SCHOTTÉ, Jacques BOUGET, Ruxandra COJOCARU, Pierre-Alexis RAYNAL, Antoine ECHE, Nesrine BENAOUICHA, Gilles POTEL, Eric BATARD
11:10

Monday 03 October

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A22
11:10 - 12:40

State of the Art
Resuscitation

Moderators: Lance BECKER (USA), Wilhelm BEHRINGER (Director) (Jena, Germany)
11:10 - 11:40 How to get the patient back after cardiac arrest. Gavin D. PERKINS (United Kingdom)
11:40 - 12:10 How to keep the patient alive after sucessful resuscitation. Lance BECKER (USA)
12:10 - 12:40 Cardiac Arrest in special circumstances. Koen MONSIEURS (Director) (Antwerp, Belgium)
Room A-FESTSAAL

Monday 03 October

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B22
11:10 - 12:40

Austria, Germany, Switzerland Invites
Ausbildung Notfallpflege innerklinisch

Moderators: Michael LAMP (Austria), Mareen MACHNER (Germany)
11:10 - 11:40 Curriculum Notfallpflege Österreich. Michael LAMP (Austria)
11:40 - 12:10 Curriculum in der Schweiz. Christian ERNST (Switzerland)
12:10 - 12:40 Curriculum in Deutschland. Mareen MACHNER (Germany)
Room B-ZEREMONIENSAAL

Monday 03 October

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C22
11:10 - 12:40

Philosophy & Controversies
P&C Pre-hospital

Moderators: Christoph REDELSTEINER (Prof) (Wien, Austria), Stefan TRENKLER (Košice, Slovakia)
11:10 - 11:40 Prehospital staff controversy: Physicians, Nurses, Paramedics. Carmen Diana CIMPOESU (Prof. Head of ED) (IASI, Romania)
11:40 - 12:10 Relation between electrical and mechanical myocardial activity during cardiac arrest. Roman SKULEC (Head of research and science department) (Kladno, Czech Republic)
12:10 - 12:40 New challenges: Telemedicine. Eric REVUE (Chef de Service) (Paris, France)
Room C-PRINZ EUGEN SAAL

Monday 03 October

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D22
11:10 - 12:40

Administration Management
Resilience - EM more than just medicine? Leadership, resilience & career satisfaction - the how to guide!

Moderators: Dr Tajek HASSAN (Board Chair for Europe, IFEM) (Leeds, United Kingdom), Marc SABBE (Medical staff member) (Leuven, Belgium)
Speakers: Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, Hong Kong), Dr Tajek HASSAN (Board Chair for Europe, IFEM) (Leeds, United Kingdom), Dr John HEYWORTH (Consultant) (Southampton, United Kingdom), Marc SABBE (Medical staff member) (Leuven, Belgium)
Room D-FORUM

Monday 03 October

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E22
11:10 - 12:40

State of the art
Psychosocial Emergencies

Moderators: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Karin RHODES (USA)
11:10 - 11:40 Screening and intervention for intimate partner violence. Karin RHODES (USA)
11:40 - 12:10 The role of ED in Mental Health Emergencies. Anne HICKS (Consultant in Emergency Medicine) (Plymouth, United Kingdom)
12:10 - 12:40 Hypnosis and therapeutic communication at the emergency department. Franck VERSCHUREN (MD, PhD) (Brussels, Belgium)
Room E-GEHEIME RATSTUBE

Monday 03 October

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F22
11:10 - 12:40

YEMD
Best articles of the year

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Jennifer TRUCHOT (MEDECIN) (Paris, France)
Speakers: Benjamin BLOOM (Consultant in EM) (Londres, United Kingdom), Pr Yonathan FREUND (PUPH) (Paris, France), Basak YILMAZ (Faculty) (Burdur, Turkey)
Room F-RITTERSAAL

Monday 03 October

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G22
11:10 - 12:40

Paediatric track
Safety in the Emergency Department

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain)
11:10 - 11:30 What is meant by safety in the ED, how to measure and to improve the care of children. Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain)
11:30 - 11:50 Lessons learned from diversity in PEM - Diversity in PEM in Europe, lessons learned from 100.000 children in 5 ED’s. Dorine BORENSZTAJN (PhD) (Rotterdam, The Netherlands)
11:50 - 12:10 Lessons learned from diversity in PEM - Antibiotic use in febrile children in paediatric emergency care – variability among Europe. Rianne OOSTENBRINK (pediatrician) (Rotterdam, The Netherlands)
12:10 - 12:30 Lessons learned from diversity in PEM - Variability in pediatric poisoning. Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain)
12:30 - 12:40 Paediatric abstracts. Henriette MOLL (paediatrician) (rotterdam, The Netherlands)
Room G-GARTENSAAL

Monday 03 October

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OP22
11:10 - 12:40

Oral Papers 22

Moderators: Hayette MOUSSAOUI (Emergency Physician) (London, United Kingdom), Inger SONDERGAARD (PHYSICIAN) (ALLEROED, Denmark)
11:10 - 12:40 #6398 - OP037 Impaired cognition is associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.
Impaired cognition is associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.

Background: The number of emergency department (ED) visits by the elderly is increasing. Cognitive impairment is a risk factor for functional decline and mortality but its assessment takes too much time in older patients in the Emergency Department. Information about cognition at arrival might be of great value to assist clinicians in making treatment decisions, to detect risk of delirium in an early phase and to reduce the risk of adverse health outcomes by implementing targeted interventions. Therefore, the aim was to investigate if the relatively brief Six-Item-Cognitive-Impairment-Test (6-CIT) is an independent predictor of functional decline and mortality, a pre-requisite to be used as a screening-tool in the acute setting.

 

Methods: A multicentre prospective observational follow-up study was conducted in patients aged 70-years or older, visiting the ED of the Leiden University Medical Center (LUMC) and Alrijne Hospital in the Netherlands. At baseline, the Six Item-Cognitive-Impairment-Test (6CIT) and functional status, as assessed with the Katz-ADL, was assessed. Cognitive impairment was defined as a 6CIT score ≥11. Multivariable logistic regression analysis with the primary outcomes mortality and functional decline (composite endpoint adverse outcome), at three and twelve months (LUMC only) after the ED visit was used.


Results: 1632 patients were included (LUMC n=751, Alrijne n=881). 326 patients (21.4%) had cognitive impairment. Compared to normal cognition, cognitive impairment is associated with increased risk of adverse health outcomes, independent of age, sex, education and triage urgency, with corrected odds ratios of 1.87 (95%CI:1.42-2.46) at three months. Patients with impaired cognition had increased risk of mortality after three and twelve months (HR 2.27(95%CI1.54-3.34)).


Conclusion
Cognitive impairment, measured with the 2-3 minute 6CIT, is independently associated with adverse health outcomes in older ED patients.

Jacinta LUCKE (Haarlem, The Netherlands), Jelle DE GELDER, Bas DE GROOT, Christian HERINGHAUS, Jaap FOGTELOO, Sander ANTEN, Gerard-Jan BLAUW, Simon MOOIJAART
11:10 - 12:40 #6419 - OP038 Clinical characteristics and outcome of nonagenarians and centenarians in a medical ICU.
Clinical characteristics and outcome of nonagenarians and centenarians in a medical ICU.

Background:

As a result of demographic transition, the proportion of « very elderly » (≥ 90 years) patients is increasing worldwide and more of these patients are nowadays admitted to intensive care units (ICU). Among physicians the discussion about appropriateness of these ICU admissions still remains controversial. mostly due to questionable outcome, limited ressources and costs. The aim of the study was to determine and evaluate the clinical characteristics and outcome in a very old population admitted to a medical ICU in an urban hospital.

Methods:  

We present here a retrospective and monocentric study. We reviewed the charts of all patients (≥ 90 years) admitted to a medical ICU between 2005 and 2015. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the ICU stay. A long-term survival follow-up was also performed. 185 patients were included for statistical analysis.

Results:

A total of 185 patients were included, which represented 1.8% of admissions to the ICU during this 10 year period. The mean age was 92.7 +/- 2.2 years, the sex ratio was 0.34. Most of patients (39%) were admitted from the emergency department (ED) and 34% directly from pre-hospital care (EMS). The mean Charlson comorbidity score was 7.6 (95% CI: [7.3-7.8]) and the mean McCabe score was 1.36 (95% CI: [1.28-1.43]). The admission diagnosis in the ICU was mainly respiratory distress (48%), septic shock (13%), coma (11%) and cardiac arrest (10%). The average SAPS-II score within 24 hours of ICU admission was 58.1+/-23.2. 20% of these patients suffered of previous dementia. 50% of patients required support by mechanical ventilation (mean duration 7.1 days) and 6% of patients received renal replacement therapy. ICU and hospital mortality rates were 40% and 46% respectively. Overall survival at three months after hospital discharge was 48%. For 34% of these patients, a limitation of active treatment was decided (on average after two days of stay). For 66% there was no justification for limiting care because of a well-established treatment plan (with family, GP, ICU team).

Conclusion:

The proportion of elderly patients remains low, but they are increasingly being treated in intensive care units. The in-hospital mortality is high (40%) compared to the average mortality in our ICU over the same period (20%). The prognosis is often not as poor as perceived by physicians. The indication for ICU treatment in our study was mostly justified ; in the setting of  consistent patient care and good clinical practice. It remains therefore appropriate to discuss every ICU admission of elderly patients without any restriction related to age.

Pierrick LE BORGNE (Strasbourg), Sophie COURAUD, Charles-Eric LAVOIGNET, Jean-Etienne HERBRECHT, Alexandra BOIVIN, Quentin MAESTRAGGI, Pascal BILBAULT, Francis SCHNEIDER
11:10 - 12:40 #7128 - OP039 Intelligent Assistance Services and Personalized Learning Environments for Support of Knowledge and Performance in Interdisciplinary Emergency Care.
Intelligent Assistance Services and Personalized Learning Environments for Support of Knowledge and Performance in Interdisciplinary Emergency Care.

Background:

During the past decade emergency medicine evolved to an increasing challenge for clinics of all stages of patient care due to a substantial and continous change of medical knowledge, limits of time and health care economics as well as an enormous rise of patient cases. Thus, continuous medical education for all employees involved in the preclinical or clinical phase of emergency care represents an essential prerequisite for high quality patient-centered care to overcome these problems. However, in this special setting of rush, stress and highly intense workload conventional learning techniques do not allow for continous training on the job. To address this problem we developed novel learning and teaching strategies based on digital technologies for both academic and non-academic staff members within interdisciplinary emergency care departments (ED).

 

Methods:

For medical students and trainees we created a podcast and an emergency care software for simulation of emergency cases in order to prepare for the work within the ED in comparison to control groups without access to these learning tools. Acceptance, frequency of usage and effects of these techniques were assessed prior to and after the occupation within the ED by standardized questionnaires and tests. For nurses and paramedics we first assessed the information demands during all processes of emergency patient care in the preclinical and clinical phase. Based on these needs intelligent assistance services were established in cooperation with two technological partners to support daily workflow via web-based services.

 

Results:

Introduction of the podcast and the emergency care software prior to the start within the ED resulted in a significant improvement of skills and expert knowledge for both medical students and trainees in comparison to the control groups (p< 0.002). Both innovative tools were widely accepted and frequently used by each proband. Analysis of processes within the preclinical and clinical phase of emergency care revealed information demands for paramedics and nurses especially with respect to invasive/non-invasive techniques, first aid standard operating procedures, medications and medical devices. Content for these assistance services was developed and subsequently digitalized for web-based usage via mobile devices (tablets). Preliminary results of these applications will be demonstrated and evaluated in a pilot study.

 

Conclusions:

Introduction of novel learning and teaching strategies within the ED allows for a continuous medical education and training on the job in the special setting characteristics of emergency care. Results of our studies revealed a significant improvement of technical skills and medical expertise thus leading to a better performance of the academic staff within the ED. Further studies with non-academic employees now have to evaluate the effects of these innovative strategies within the preclinical and clinical phase of emergency care.

Sabine BLASCHKE (Goettingen, Germany), Bjoern SELLEMANN, Carsten ULLRICH, Michael SCHMUCKER, Katrin WEDLER, Sabine REY, Stefan ROEDE, Markus ROESSLER, Otto RIENHOFF, Felix WALCHER, Martin HAAG, Christoph IGEL
11:10 - 12:40 #7243 - OP040 Use of Physical restraint on elderly people in emergency department.
Use of Physical restraint on elderly people in emergency department.

Background: Confusion in elderly people presenting to Emergency Department (ED) is often associated with a state of agitation with or without aggressivity. Recommendations for the management of these patients exist. Physical restraint (PR) is sometimes necessary to protect them but it is a source of morbidity and mortality. The aim of our study was to examine how emergency physicians prescribe physical restraint for elderly people presenting to ED. The primary outcome was association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR.

Methods: Elderly people (age > 75 years old) with prescription of PR were included in this retrospective study between november 2014 and march 2015 in Lariboisière University Hospital, Emergency Department . Two groups were compared on such criteria: 1 / PR alone (group A); 2 / PR + chemical treatment (group B). The primary outcome was the association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR. The secondary outcomes were justified prescription of PR, revaluation of the indication of PR and monitoring of the PR. The student test was used for quantitative variables. The Chi 2 test was used for qualitative variables.


Results: One hundred thirty-eight consecutive patients were analyzed (66 [48%] in group A and 72 [52%] in group B) with no significant difference between the 2 groups (p = 0.32). The prescription of benzodiazepine associated with PR was significantly higher compared to the prescription of neuroleptic. The number of justified prescription of PR was higher but not significantly different (p = 0.05) in group B (n = 18 [25%]) than in group A (n = 8 [12%]). Half of justified prescription of PR was linked to an act of nursing care. The daily revaluation of the PR was significantly higher in group B (respectively 11 [15%] vs 0 in group A, p <0.01).

Conclusion: Elderly people having PR did not always have an associated chemical treatment as provided by the recommendations. The prescription of PR were insufficiently justified. The daily revaluation of the indication of the PR and clinical-biological monitoring were almost non-existent causing a risk of increased morbidity and mortality. This study justified the establishment of a protocol to guide the prescription of the PR in elderly people in our ED.

Erwin HANSCONRAD (Vincennes), Anthony CHAUVIN, Patrick PLAISANCE
11:10 - 12:40 #7415 - OP041 Adverse events in elderly patients admitted to a medical short stay unit.
Adverse events in elderly patients admitted to a medical short stay unit.

Introduction

Elderly patients are at particular risk of experiencing adverse events of hospitalisation, and they are more vulnerable to adverse events compared to younger patients. The aim of this study was to compare the occurrence of adverse events during hospitalisation or within 30 days after discharge to either a short stay unit or a department of internal medicine in elderly internal medicine patients.

Methods

This retrospective study evaluated adverse events during hospitalisation of elderly internal medicine patients either in an emergency department based short stay unit called ‘Quick Diagnostic Unit’ (QDU) or an internal medicine department (IMD) at Holbaek Hospital, Denmark, from January 1st 2014.. Eligible patients were 75 years or older and admitted for any internal medicine disease and they should have a non-emergent (green) triage level at admission. IMD patients were matched with QDU patients by 1) year of birth and 2) date of admission. Medical records were reviewed in a two-stage process by physicians to detect adverse events. Earlier studies have shown that up to 37 % of elderly patients experience an adverse event during a hospitalisation; to detect a 33 % risk reduction based on alpha=0.05 and beta=0.08, a sample size of 450 patients was required. The primary outcome was the occurrence of any adverse event on a list of 19 predefined events during hospitalisation or up to 30 days after discharge. Secondary outcome measures included types of adverse events and mortality. A p-value <0.05 was considered significant.

Results

We screened a total of 833 patients’ hospital charts for inclusion and 450 patients met the inclusion criteria, 225 patients in each group. The median age of patients were 82 years (IQR 78-86 years) for both groups. There were no significant differences in baseline variables. For both groups, the median Charlson Comorbidity Index score was 6 with IQR 5-7. Adverse events were significantly less common in the QDU-group than in the IMD-group, i.e., 68 (30 %) patients in the QDU-group and 92 (41 %) patients in the IMD group had one or more adverse events of hospitalisation, (p=0.02). The relative risk of an adverse event was 0.80 (95 % CI 0.65-0-99) in the QDU-group and 1.23 (95% CI 1.02-1.15) in the IMD group, respectively. The most common adverse events were 1) transfer during hospitalisation, 2) unplanned readmission, 3) nosocomial infection in both groups. We found no significant difference in 90-day mortality QDU-group compared to the IMD-group, 65 (29 %) versus 84 (37%) (HR 0.729 (95% 0.414-1.284)).

Conclusions

Adverse events was significantly less common in elderly patients treated in a medical short stay unit compared to an internal medicine ward. Hospitalisation in a short stay unit seems not only feasible, but in selected cases maybe even preferable, for elderly medical patients.  

Dr Camilla STRØM (Copenhagen, Denmark), Lars Simon RASMUSSEN, Thomas Andersen SCHMIDT
11:10 - 12:40 #7631 - OP042 Attitudes and knowledge of emergency medicine health care professionals toward elder abuse and neglect.
Attitudes and knowledge of emergency medicine health care professionals toward elder abuse and neglect.

Introduction: Elder abuse is a significant public health problem. The population of elder people is increasing steadily. According to World Health Organization (WHO), by the year 2050, it is expected that the number of elder people would have come up to 20 percent of world population. Although the elder abuse and neglect prevalence is higher than supposed, it is much lower to identify and report these cases, especially in emergency medicine departments. The aim of this study is to assess the knowledge and attitudes of emergency medicine health care professionals toward the identification and management of elder abuse and neglect cases.

Methods: This cross-sectional descriptive study was performed in two universities and two training and research hospitals’ emergency departments in Ankara.  The research tool was a 26-item questionnaire that was applied on 184 emergency medicine health care professionals including doctors, nurses, emergency medicine technicians.  Analysis was completed with SPSS 15.0. In addition to descriptive statistics, chi square analysis were used to determine differences between groups.

Results: Although 78% of participants had identified an abuse elder person before, 64% of them have never reported about elder abuse. The main reasons of not reporting are not to feel proficient (41%) and not know how to do that (27%). Significant percent of responders answered that they haven’t had any education about elder abuse and neglect in undergraduate education (73%) and post-graduate education (87%).

Conclusion: This study indicates that emergency medicine health care professionals confronts with abused elder frequently but they abstain from reporting these cases because they feel lack of knowledge about elder abuse and neglect especially.

References:

  1. Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Archives of Gerontology and Geriatrics 43 (2006) 267–276.
  2. Fulmer T, Paveza G, Abraham I, Fairchild S. Elder neglect assessment in the emergency department. Journal of emergency nursing: 2000 vol: 26 (5) pp: 436-443.
  3. Almogue A, Weiss A,  Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Archives of Gerontology and Geriatrics 51 (2010) 86–91.

Acknowledgements: There is no funding received for this work from any organizations. The authors declare that they have no conflict of interest.

Aysegul GUVEN CEBECI (Ankara, Turkey), Isa KILICASLAN, Fikret BILDIK, Sezer ESFER, Reyhan SAHNAOGLU
11:10 - 12:40 #7906 - OP043 Triage training in mass casualty incidents: the added value of virtual simulation in e-learning and classroom teaching.
Triage training in mass casualty incidents: the added value of virtual simulation in e-learning and classroom teaching.

Background: The traditional model of education in medical schools is based on the belief that students will successfully transfer knowledge gained in classroom lectures, completed by self-education trough e-learning. More educational programs are also starting to integrate simulation based learning into their teaching methods. Several studies suggest that clinical simulation is an effective teaching strategy, although it is very depending on the context, topic and method.  Finding out what is the most impactful methodology leading to the best learning and knowledge retention over time is desirable.

The present study was designed to evaluate the added value of virtual simulation programs in teaching START triage to medical students, compared with e-learning and classroom teaching.

 

Methods: Twenty medical students were randomly assigned into two groups: group A and group B. Both groups were given the same classroom lecture, supported by a PowerPoint presentation on how to perform START triage in Mass Casualty Incidents (MCI). Immediately following this lecture, a 30-item paper-based test was administered to assess the student’s ability to understand and apply START triage.

Both groups received a more extensive online presentation with examples and video’s through e-learning. Group B had an additional interactive session with virtual simulation training and professional feedback.

One month later a new test was given to assess and compare knowledge between both groups.

 

Simple descriptive statistics were used to analyse findings, with the independent samples T-test to compare groups where appropriate. For further analysis nonparametric statistics were used due to some indications of possible non-normality.

Alpha was set at p < 0,05 to determine statistical significance. All analyses were conducted using SPSS® software.

 

Results: The baseline test showed a mean score of 15,65 out of 30. For the second test, taken after the thirty-minute classroom teaching session an average score of 26,15 out of 30 was observed. This statistically significant change (Independent‐SamplesMann‐Whitney‐U test, p < 0,001) showed a strong improvement in knowledge after a brief classroom teaching session. After one month of e-learning group A had an average score of 28,6 out of 30. Group B, who received the additional virtual simulation session, scored 28,875 out of 30.

This result didn’t reveal any statistically significant difference between both groups (Independent-Samples Mann-Whitney-U test, p = 0,696).

Also examined was the number of over- and undertriaged casualties, but no significant differences were found between either group. No differences between men and women were noted.

 

Conclusion: Although virtual simulation training has been described in literature as an effective teaching strategy, no significant differences in scores on knowledge tests were found between two test populations of which one received ‐ in addition to classroom lecture and e‐learning ‐ a computer‐based virtual reality simulation training.

Nevertheless, certain findings in this study were surely intriguing opportunities for further research. A comparable study with a larger test group, a more extensive teaching subject and/or a longer time interval between the tests could be interesting pathways to investigate.

Sofie-An VAN BIESEN (Aalst, Belgium), Nima TABRIZI-HOSSEINPOUR, Joost BIERENS, Ives HUBLOUE
11:10 - 12:40 #7987 - OP044 Methodological characteristics and outcomes used in simulation randomized controlled trials in the field of Emergency Medicine: a systematic review.
Methodological characteristics and outcomes used in simulation randomized controlled trials in the field of Emergency Medicine: a systematic review.

Background: Simulation is defined as a technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. The use of simulation in emergency medicine began decades ago with the use of low-fidelity simulations and has evolved at an unprecedented pace. The literature on simulation is abundant in emergency medicine. But the methodological quality of these studies had not yet been assessed. The aim of this study was to conduct a systematic review of published randomized controlled trials (RCT) assessing a simulation intervention and to examine their methodological characteristics.

Methods: We performed a systematic review on MEDLINE via PubMed of randomized controlled trials, assessing a simulation intervention, published from January, 1st 2012 to December, 31th 2015 in the 6 general and internal medicine journals, and the 10 emergency medicine journals with the highest impact factor according to the Institute for Scientific Information Web of Knowledge. Two researchers independently performed the trials selection and extracted the data, if necessary a third researched stepped in to resolve disagreements. For each trial, researchers extracted the RCT general characteristics, the participants, intervention, comparator and outcomes as reported in the trial report. The Cochrane Collaboration risk of bias tool was used to assess the trials risk of bias, using the tool main domains (sequence generation, allocation concealment, blinding of participants, blinding of outcome accessors, incomplete data management and selective reporting). Methodological quality was evaluated using the MERQSI score. The MERSQI is a tool used to assess educational interventions.

Results: 1 394 RCTs were screened, 270 (19%) were considered as in the field of emergency medicine and 69 (26%) assessed a simulation intervention. Fifty-five RCTs were monocentric. The average time of acceptance was 143 days (SD=86). Studies included on average 144 participants. United States of America were the most frequent place of study. In included trials, cardiopulmonary resuscitation (CPR), was the most frequent topic (n=55; 80%). The usual procedure was the comparator in half studies (n=37). 30 (43%) of RCTs were evaluated for CPR quality outcomes. A total of 10% (n=7) were registered on a public registry or had an available protocol. The random sequence generation and allocation concealment were correctly performed respectively in 68% (n=47) and 43% (n=30).The participants and assessors blinding were correctly performed in 20% (n=14) and 62% (n=43). The attrition bias was low in two-third in studies (n=50). The reporting bias was low in nearly all studies (n=65; 95%).Methodological quality by MERQSI score averaged 12.3/18 (SD=3).

Conclusions: Trials assessing simulation count fo one quarter of published RCTs in emergency medicine. Their quality remains unclear and should make us very cautious when interpreting their results. In our sample authors particularly failed to correctly describe the blinding and allocation concealment. These trials characteristics being associated with the magnitude of the intervention effect based on previously published meta-epidemiological studies.

Chauvin ANTHONY (Paris), Jennifer TRUCHOT, Dominique PATERON, Patrick PLAISANCE, Youri YORDANOV
11:10 - 12:40 #7997 - OP045 The Phenomenon of Older Emergency Department Frequent Attenders.
The Phenomenon of Older Emergency Department Frequent Attenders.

Introduction:

Characteristics of older frequent users of Emergency Departments (EDs) are poorly understood. Our aim was to examine the characteristics of the ED frequent attenders (FAs) by age (<65 and ≥65 years).   

Methods: 

We examined the prevalence of FA attending the ED of an urban teaching hospital in cross-sectional study between 2009 and 2011. FA was defined as a person who presented to the ED four or more times over a 12-month period. Randomly selected groups of FA and non-FA from two age groups (<65 and ≥65 years) were then examined to compare characteristics between older FAs and non-FAs and older FAs and younger FAs. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals for 12-mortality in FA compared to non-FA aged ≥65years.

Results: 

137,150 ED attendances were recorded between 2009 and 2011. 21.6% were aged ≥65years, 4.4% of whom were FAs, accounting for 18.4% of attendances by patients over 65 years. There was a bi-modal age distribution of FA (mean ±SD; <65years 40±12.7; and ≥65years 76.9±7.4). Older FAs were 5 times more likely to present outside normal working hours and 5.5 times more likely to require admission. Cardiovascular emergencies were the most common complaint, in contrast with the younger FA group, where injury and psychosocial conditions dominated. The OR for death at 12-months was 2.07 (95% CI 0.93, 4.63), p=0.07, adjusting for age and gender. 

Conclusion:

1-in-5 ED patients over 65years are frequent attenders. Older FAs largely presented with complex medical conditions. Enhanced access to expert gerontology assessment should be considered as part of effective intervention strategies for older ED users.  

Geraldine MCMAHON, Megan Power FOLEY (Dublin, Ireland)
Room OP-SCHATZKAMMERSAAL
12:55

Monday 03 October

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G-EB
12:55 - 13:55

Getting to know the EBEEM
Q&A for specialist educators, trainees and candidates

Moderators: Ruth BROWN (Speaker) (London, United Kingdom), Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, Sweden)
Room G-GARTENSAAL
14:10

Monday 03 October

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A23
14:10 - 15:40

State of the Art
Geriatric

Moderators: Jay BANERJEE (Leicester, United Kingdom), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
14:10 - 14:40 Management of Confusion in older patients in the ED. Jacinta A. LUCKE (Emergency Phycisian) (Haarlem, The Netherlands)
14:40 - 15:10 Evaluation and resuscitation of older patients in the pre hospital and ED settings. Mehmet Akif KARAMERCAN (Chair of EuSEM Research Committee) (ANKARA, Turkey)
15:10 - 15:40 Management of Brain Injury in Older Patients in the ED. Richard WOLFE (Boston, USA)
Room A-FESTSAAL

Monday 03 October

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B23
14:10 - 15:40

Austria, Germany, Switzerland Invites
Pflege - Notfallpflegekompetenz

Moderators: Florian GROSSMANN (Clincal Nurse Specialist) (Basel, Switzerland), Susanne SCHUSTER (Germany)
14:10 - 14:40 Notfallpflegekompetenz aus der Perspektive der Schweiz. Florian GROSSMANN (Clincal Nurse Specialist) (Basel, Switzerland)
14:40 - 15:10 Notfallpflegekompetenz aus der Perspektive Deutschlands. Susanne SCHUSTER (Germany)
15:10 - 15:40 Notfallpflegekompetenz aus der Perspektive Österreichs. Thomas WAGNER (Austria)
Room B-ZEREMONIENSAAL

Monday 03 October

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C23
14:10 - 15:40

Philosophy & Controversies
P&C Resuscitation

Moderators: Gavin D. PERKINS (United Kingdom), Peter STRATIL (VIENNA, Austria)
14:10 - 14:40 ECMO Pros and Cons: You must choose wisely. Lance BECKER (USA)
14:40 - 15:10 To epinephrine or not to epinephrine during cardiac arrest? Gavin D. PERKINS (United Kingdom)
15:10 - 15:40 Targeted temperature management after cardiac arrest: when, how deep, and how long? Wilhelm BEHRINGER (Director) (Jena, Germany)
Room C-PRINZ EUGEN SAAL

Monday 03 October

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D23
14:10 - 15:40

EUSEM meets ACCA/ESC

Moderators: Pr Abdelouahab BELLOU (Research) (Boston, USA), Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany)
14:10 - 14:40 Major bleeding in patients on oral anticoagulants (VKA or NOAC). Kurt HUBER (VIENNA, Austria)
14:40 - 15:10 Management of acute hypertension in the ED. Pr Abdelouahab BELLOU (Research) (Boston, USA)
15:10 - 15:40 Strategies to rule in and rule out causes of acute chest pain in the ED. Madalenna LETTINO (ACCA President Elect) (Italy)
Room D-FORUM

Monday 03 October

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E23
14:10 - 15:40

Research
Pre-hospital

Moderators: Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic), Roman SKULEC (Head of research and science department) (Kladno, Czech Republic)
14:10 - 14:40 EuSM prehospital systems survey 2016. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)
14:40 - 15:10 EMS systems´comparison across the cases. Christoph REDELSTEINER (Prof) (Wien, Austria)
15:10 - 15:40 Cardiac arrest on board: How safe are we on the plane? Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, Czech Republic)
Room E-GEHEIME RATSTUBE

Monday 03 October

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F23
14:10 - 15:40

YEMD
Point of care Ultrasound: batman returns

Moderators: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
14:10 - 14:40 POCUS, hype or reality: will it replace the stethoscope? James CONNOLLY (Consultant) (Newcastle-Upon-Tyne)
14:40 - 15:10 The times they are A-changin` - where US is replacing Xray today and where tomorrow. Pr Joseph OSTERWALDER (Head of Hospital) (St. Gallen, Switzerland)
15:10 - 15:40 Can point of car ultrasound turn into a weapon of mass destraction. Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
Room F-RITTERSAAL

Monday 03 October

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G23
14:10 - 15:40

Paediatric track
Research

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Mark LYTTLE (Bristol, United Kingdom), Ian MACONOCHIE (United Kingdom), Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain)
14:10 - 15:20 Workgroup session with experts. Henriette MOLL (paediatrician) (rotterdam, The Netherlands), Mark LYTTLE (Bristol, United Kingdom), Liviana DA DALT (PHYSICIAN) (PADOVA, Italy), Laurence LACROIX (Consultant) (Geneva 14, Switzerland)
1. Systematic review, 2. observational trials, randomised controlled trials, 3. information resources, 4. REPEM + PERN. Groups of 10 participants rotate to each table every 20 minutes.
15:20 - 15:40 Paediatrics abstracts. Henriette MOLL (paediatrician) (rotterdam, The Netherlands)
Room G-GARTENSAAL

Monday 03 October

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OP23
14:10 - 15:40

Oral Papers 23

Moderators: Anthony CHAUVIN (MCU-PH) (Paris, France), Jeffrey KEEP (London, United Kingdom)
14:10 - 14:20 #6343 - OP046 Emergency Department blood-borne Virus Screening Study (EDVS STUDY). Feasibility and results in an urban inner city Emergency Department.
Emergency Department blood-borne Virus Screening Study (EDVS STUDY). Feasibility and results in an urban inner city Emergency Department.

Introduction

Recent data suggests >2/1000 people live with HIV in the Dublin area. British HIV Association guidelines advise universal HIV testing at this threshold. Reported prevalence of Hepatitis C (HCV) in Ireland is 0.5- 1.2%. Hepatitis B (HBV) prevalence is unknown. The aim of this study was to assess the feasibility of a HIV, HBV and HCV panel screening programme in an urban Emergency Department (ED).

 Methods

With ethical approval, opt-out serum screening was piloted from March 2014 to January 2015. Patients who underwent venepuncture in ED were offered an additional panel viral screen of HIV, HBV and HCV testing. An extensive staff education programme was conducted before the study commenced. Visual and verbal reminders were instituted at daily staff handovers. The study organisers provided regular study updates.

Results

Of 10,000 samples, 8839 were analysed following removal of duplicates. A sustained uptake of >50% of samples was attained by Week 3.

97, 44 and 447 patients tested positive for HIV, HBV and HCV respectively. Of these, 7, 20 and 58 were new diagnoses of HIV, HBV and HCV respectively. The incidence and prevalence of all three viruses are outlined below

HIV- incidence 0.8 per 1000, prevalence 11 per 1000

HBV- incidence 2.26 per 1000, prevalence 5.05 per 1000

HCV- incidence 6.5 per 1000, prevalence 50.5 per 1000

Conclusions

The results demonstrate a high prevalence of blood borne viruses in our population. Opt-out serum screening for blood borne viruses is feasible and acceptable in a busy urban ED for both staff and patients. It has now become standard of care in our Emergency Department.

Darren LILLIS (Dublin, Ireland), S O'CONNELL, A COTTER, S O'DEA, H TUITE, Darragh SHIELDS, S NORRIS, B CROWLEY, Pk PLUNKETT, C BERGIN
14:20 - 14:30 #6507 - OP047 The diagnostic value of optic nerve sheath diameter measurements by ultrasonography in elevated intracranial pressure in stroke patients.
The diagnostic value of optic nerve sheath diameter measurements by ultrasonography in elevated intracranial pressure in stroke patients.

Indtroduction:Stroke is the most common 4th cause of death around the world. Due to brain edema elevated ICP is a reason of clinical deterioration in stroke patients  (%33).  ONSD measurement with ultrasonography is an indirect and non invasive technique to detect EICP.

Aim:The aim of this study is to invastigate the diagnostic value of ONSD measurements in EICP in stroke patients.

Methods:The paper involves data concerning a control group 50 individuals with study group of 105 patients diagnosed with acute stroke at the Adult Emergency Department of Hacettepe University between February 1,2015 and June 30,2015.  Symptoms and physical examinations of the patients were recorded. We performed ON-US to all patients and ONSD measurements by US were compared with the results of study group MRI-ONSD measurements. 

Results:MRI-ONSD measurements were used to diagnose EICP and the cut off for EICP was 5.0 mm in MRI-ONSD. The study group divided in two subgroups as EICP (n=47) and non-EICP (n=58) groups. Of the 155 patients studied, 81 (%52,3) were male and 74 were (%47,6) female. The means of ONSD by US; for non-EICP group for right and left eye were 4,52 mm/4,58 mm, for EICP group were 5,01 mm/5,03 mm. The means of MRI-ONSD for EICP group were 5,05 mm/5,06 mm and non EICP group were 4,56 mm/4,61 mm. Greater than 5,0 mm ONSD by US predicted EICP with sensitivity %95,7; specificity %100, general truth value %91,4 and kappa %82,8. The means of ONSD by US were significantly correlated with MRI-ONSD measurements. Symptoms such as headache, confusion and vomiting were significantly higher in EICP group and these symptoms predicted EICP with sensitivity %95,7; specificity 87,9. The intensive care requirement was increased in EICP group rather than non-EICP group (%25,5/%6,9).  Especially MCA infarction associated with brain edema (%65,7) and elevated mortality rate (%14,3). 5 patients (%4,76) were exitus in intensive care unit and all the patients had MCA infarction.

Conclusion:As a result, ONSD measurements by US is sufficient, reliable and practical in the diagnosis of acute stroke. ICP assessment with ON-US in acute stroke patients could be used to predict treatment process, prognosis and mortality.

Ali BATUR, Mehmet Ali KARACA (ISTANBUL, Turkey), Volkan ARSLAN, Mustafa BOZ, Bulent ERBIL, Zaur IBRAHIMOV, M.ruhi ONUR
14:30 - 14:40 #7143 - OP048 The Efficieny Of Ultrasonography For Reduction of Distal Radial Fractures In The Emergency Deapartment.
The Efficieny Of Ultrasonography For Reduction of Distal Radial Fractures In The Emergency Deapartment.

Introduction: Distal radius fracture is the most common fracture of the wrist. Adequacy of reduction is evaluated through two-way post-reduction graphies. In the event that inadequate reduction is ascertained in the wake of the evaluated graphies, sedation and reduction procedures are performed on the patient once again. Ultrasonography (USG) can be used in the management of the patients with distal radius fractures, however, there are no adequate number of studies suggesting the efficiency of USG alone in showing the status of reduction success. The aim of the study is to evaluate the efficiency of the use of bedside USG for determining reduction success distal radius fractures and  to investigate the detecttability of the possible causes leading to unsuccessful reduction when using USG. 

Methods: Consecutive patients applied to the emergency department of the Faculty of Medicine of Ege University between the period, April 2013–September 2013, were incorporated into this prospective double-blind cross-sectional study. The patients aged over 18, who had wrist trauma and distal radius fracture and on whom reduction was performed were included to the study. Pre- and postreduction ultrasonographic images were recorded by a research asistant trained in extremity ultrasonography, images were recorded in longitudinal and horizontal axes. 

Separately, emergency medicine specialist (EMS)also, by examining the ultrasonographic images, evaluated the angulation of the distal fragment towards the dorsal or volar part, and whether or not there was any shortening in the radius, and whether there were any multiple fragments in the dorsal part of the distal fragment. The post-reduction graphies were re-evaluated in terms of reduction success by another orthopedic surgeon uninformed about the performed procedures. The orthopedic surgeon evaluated the reduction success and, the radial height: ≥5mm, radial angulation: between 15⁰-25⁰ , and the volar tilt angle: between  0⁰-20⁰  were considered as normal values. Evaluation of orthopedic surgeon was accepted as gold standart and compared with EMS. Sensitivity, specificity, and positive and negative predictive values were measured.  

Results: Ulltrasonography was 97,5% sensitive and 95% specific in determining the reduction success, the positive predictive value (PPV) was found as 97,5%, whereas the negative predictive value (NPV) was found as 95%. When direct graphy was accepted to be the golden standard, the direction of the distal fragment was determined with 100% sensitivity and 100% specificity through ultrasonography (PPV:100%, NPV:100%). The number of the multiple fragments was determined with 86% sensitivity and 73% specificity with use of ultrasonography (PPV: 84%, NPV: 77%), while the presence of radial shortening was ascertained with 67% sensitivity and 65% specificity (PPV: 79%, NPV: 50%).

Both ultrasonography and direct graphy was determined that distal fragment located towards the volar and presence of multiple distal fragments had negatively affected the reduction success significantly. However ultrasonography was failed to determine reduction success in the presence radial shortening (p=0,582)  when direct graphy succesfully determined the reduction success (p=0.008). 

Conclusion: Ultrasonography can be helpful in determining the reduction success for distal radius fractures which needs reduction. In the future, using ultrasonography may boost reduction success prominently in the ED.

Ozgur BOZKURT, Pr Murat ERSEL (IZMIR, Turkey), Funda KARBEK AKARCA, Sercan YALCINLI, Sadiye MIDIK, Levent KUCUK
14:40 - 14:50 #7380 - OP049 Emergency Department Applicability of SOFA Sepsis – Is There a Middle Ground?
Emergency Department Applicability of SOFA Sepsis – Is There a Middle Ground?

Background – 2016 has seen the publication of new definitions for sepsis and further evaluation of the SOFA sepsis scoring system. With little involvement from Emergency Department (ED) physicians, the problem now is applying them to the first few hours of patient care. The ED requires a system that sits between the blunt triage tool of 'quick SOFA' (qSOFA) and the intensive-care based and considerably more detailed SOFA Sepsis score.  The key area of difficulty with applying the SOFA score is that it relies on changes from patient’s baseline. This baseline information, however, is rarely available in its entirely in the critical period of the patient’s initial care in the ED. Assuming a baseline score of 0 for all patients will clearly result in overdiagnosis of sepsis in the ED.

Aims

  • to illustrate the difficulties in applying the SOFA score within a representative ED population in comparison to the qSOFA and National Early Warning Score (NEWS)
  • to develop and test an adapted SOFA score (EDdeltaSOFA) with specific, pragmatic assumptions for the ED relating to existing physiological baseline and pre-existing disease.

Methods

A retrospective analysis was performed of one month’s patients notes who had been coded for ‘infection’ within an ED database. The NEWS and qSOFA score were calculated from recorded vital signs at triage. These scores were then applied against the SOFA score (calculated from blood tests and physiological parameters within the ED) necessarily assuming a baseline as 0 and then against an adapted score.

This adapted SOFA score, the 'EDdeltaSOFA' utilises all the same categories as the SOFA score but allows for a few pragmatic assumptions based on prior knowledge or reasoned clinical suspicion of the patient’s baseline physiology. For example, for renal impairment, where previous creatinine is not known but the patient has a history of chronic renal impairment, it seems reasonable to assume a baseline SOFA score of 1 rather than a baseline score of 0.

Results

Within the sample of 169 patients who met criteria, 34 patients were excluded with missing data. 57 patients were positive for SOFA sepsis within the sample with only 42 meeting criteria with the adapted EDqSOFA score. NEWS and qSOFA performed poorly for predicting SOFA sepsis when the patient’s baseline physiology score was assumed to be zero. NEWS sensitivity 54% (C.I.s 41-67) specificity 43% (C.I.s 31-54) and qSOFA 55% (C.I.s 42-68) specificity 66% (C.I.s 54-76). They performed better when the EDqSOFA score was applied. NEWS sensitivity 88% (C.I.s 74-96) specificity 49% (C.I.s 39-59) and qSOFA 71% (C.I.s 55-84%) specificity 69% (C.I.s 58-78%)

Conclusion:

The new definitions of 2016 are an extremely welcome step forward in our understanding of the elusive clinical entity of sepsis. It is now the role of Emergency Physicians to apply the knowledge to our clinical environment. The data presented above suggests that there is a promising method of adapting the SOFA sepsis score. It is the authors’ intention to develop this tool further and conduct a series of larger validation trials for its use.

Tom ROBERTS, Danny YOOKEE, Matt EDWARDS (London, United Kingdom), Jeff KEEP
14:50 - 15:00 #4547 - OP050 Follow-up review of the impact of national jaundice guidance (NICE CG98) on inappropriate attendances to a paediatric emergency department.
Follow-up review of the impact of national jaundice guidance (NICE CG98) on inappropriate attendances to a paediatric emergency department.

Background

NICE guidelines (NICE CG98) launched in May 2010 on neonatal jaundice mandate quantitative bilirubin testing in every neonate noticed to be visibly jaundiced. The guidelines were implemented locally in August 2011, and consequently, caused a significant surge in the number of attendances to our paediatric emergency department (ED) for bilirubin level assessments, straining emergency services significantly, as seen in a review done in 2012. Transcutaneous bilirubinometers were purchased for local midwifery teams to enable quantitative bilirubin testing in the community. This study was undertaken to review the impact of the NICE guidelines and the provision of trancutaneous bilirubinometers since.

Materials

Review of hospital episode statistics from November 2014 to August 2015 as recorded on EPIC and comparison of ED attendances against the local birth rates and inpatient admissions with neonatal jaundice as a diagnosis; and comparing this against a similar review of the data undertaken in 2012. Review of the proportion of admissions and bed days for feeding and observation compared to phototherapy and septic screens.

Results

From the previous review done in 2012 in the department, pre-guideline implementation saw an average of 14.5 patients per month present to the paediatric ED with jaundice, rising dramatically to an average of 49 patients per month post-guideline implementation. Local birth rates remained stable at about 490 births per month. Over the same time period, admission of neonates to a paediatric inpatient ward with jaundice did not rise significantly at approximately 15 admissions per month. Over the period of November 2014 to August 2015, with the introduction of transcutaneous bilirubinometers for community midwives, which allows for quantitative assessment of bilirubin levels in the community, the attendance of patients to the paediatric ED with jaundice has fallen back to baseline of an average of 13.5 patients per month (Fig. 1). This is assuming that the local birth rate remained stable. Of these attendances, 15.5% were recalls to ED for serial serum bilirubin readings. Of these recalls, 25% were recalled for two serial bilirubin tests, while the other 75% were recalled once. Of these patients, most of them had an initial presentation of jaundice alone with no other worrying features (e.g. lethargy, fever, loss of weight). All these patients were discharged with no further follow-up.

Conclusion

Before the implementation of national guidelines, a careful assessment and anticipation of its downstream effects is required. Simple investigations made available in the community will help mitigate attendances to the emergency department, and will help reduce healthcare costs and inconvenience to patients and families. Similarly, providing, encouraging or enabling utilisation of services in the community that prevent the initial problem will help in reducing attendances at the ED and admissions for observations and support services that are already available in the community. 

Xue-En CHUANG (Bury St. Edmund's, United Kingdom), Peter HEINZ
15:00 - 15:10 #8005 - OP051 Consultus Interruptus: Unscheduled Interactions within the Emergency Department.
Consultus Interruptus: Unscheduled Interactions within the Emergency Department.

Introduction

It is well recognised that the job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.

Objectives

This study attempted to answer the following questions:

  • In a day how many unscheduled interactions does the senior EM physician deal with?

  • How many of these are interactions are clinical interactions?

  • What is the average length of time spent dealing with these unscheduled interactions?

Methods

This prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was trailed on shift by a medical student who noted down all the non-patient interactions that the consultant had. The consultant had no input into data collection. The nature of the UI, the time spent and the outcome was recorded on a simple data collection form. This was then collated and analysed.

 Results

  • A total of 23 shifts over 135hrs 34min were observed.

  • There was a mix of early (0800-1600), late (1600-2100) and weekend shifts.

  • All 10 members of the consultant body were followed.  

Total Number of UI in study period:  2082

Average Number of UI per hr:  17.95 UI/hr.

UI rate (time per UI) 3min 21seconds

Average time per UI 87.5sec   (Range 10s–34 mins)

Clinical Interaction vs Non Clinical Interactions: 94% vs 6%

Conclusion

In this single centre study of an urban UK emergency department 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 seconds

Discussion

The nature of modern EM necessitates a senior EM physician running a shift on order to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load  is not feasible and departments should consider the initiation of a ‘captain of the ship’ ‘Fat Controller’ role along with a second senior EP to provide individual consultant level care to the sickest individuals who require senior input.

Sandeep GILL (Smethwick, United Kingdom), Raj PAW, Peter DOYLE, Ameer SHAH, Sarah SHAKKSHIR, Munir ABUKHDER
15:10 - 15:20 #8142 - OP052 Assessment of fluid responsiveness in the critically ills: which role for echocardiography?
Assessment of fluid responsiveness in the critically ills: which role for echocardiography?

Background: Volume expansion is a key component of therapy in critically ill patients, although its effect is difficult to predict using conventional measurements. Dynamic parameters, evaluated by echocardiography, have demonstrated a good diagnostic accuracy in several studies, but conflicting results have been reported. Aim of this study was to examine the feasibility and diagnostic accuracy of vena cava collapsibility index (VCCI) and velocity time integral variation after passive leg raising (PLR) in an unselected population of critically ill patients admitted to a sub-intensive clinical setting.

Methods: This is a prospective, observational, pilot study. Unselected critical patients admitted in an Emergency Department High-Dependency Unit (ED-HDU) were evaluated by transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity (AoV)  variation during PLR. According to VCCI, patients were considered fluid-responders when the value was ≥50%, non-fluid responders when the collapse was <10% and indefinite response for intermediate values. According to AoV variation after PLR, a positive hemodynamic response was defined as an increase in AoV ≥ 10%. Whenever possible, both VCCI and AoV variation during PLR were evaluated. According to echocardiographic evaluation, three therapeutic options were considered: no intervention, administration of fluids or diuretics. Any change in the therapeutic strategy by the treating physician in the following 12 hours was annotated into the clinical records.

Results: we enrolled 29 patients, mean age 75±13 years; the two most frequent reasons for ED-HDU admission were sepsis (69%) and COPD re-exacerbation (14%). VCCI was feasible in 25 (86%) patients, while PLR could be performed in 13 (45%, p=0.004). According to VCCI, 11 (38%) patients were fluid-responder, 7 (24%) were non fluid-responders and in 7 patients VCCI showed an intermediate value; PLR was concordant with VCCI in 7 patients and it gave a diagnostic result in 6 patients in whom VCCI was not feasible or not diagnostic. According to the echocardiographic evaluation, 6 patients did not receive any treatment, 16 were treated with fluids and 7 with diuretics: the therapeutic option was maintained for the following twelve hours in 23 patients, while it was modified in the remaining 6 patients. This group of patients have been evaluated only by VCCI; 3 of them were fluid-responders, 2 non fluid-responders and 1 in the intermediate group. In these patients left ventricular systolic function was slightly depressed (left ventricular ejection fraction 47±9 vs 54±17% in the remaining patients) and lactate dosage was  normal (1.3±0.7 vs 2.4±3.6 mEq/L): these differences were not statistically significant, probably in part as a consequence of the limited population size, and need to be confirmed in a larger study group.

Conclusions: VCCI appears to be very feasible in an unselected population of critically ill patients; the proportion of patients with an indefinite value, who need a further evaluation, is not negligible as well as the proportion of patients in whom the therapeutic option based on VCCI measurement had to be modified in the following hours. PLR has a limited feasibility but it shows a very good diagnostic performance.   

Caterina SAVINELLI (Firenze, Italy), Salvatori MATTIA, Federico MEO, Alessandro COPPA, Francesca INNOCENTI, Riccardo PINI
15:20 - 15:30 #8174 - OP053 Factors associated with recurrent diabetic ketoacidosis in the emergency department.
Factors associated with recurrent diabetic ketoacidosis in the emergency department.

 

Introduction:

   Diabetic ketoacidosis (DKA) is one of the most commun diagnosis in the emergency department(ED). Many studies reported that DKA is the leading cause of mortality .In addition to the risk of fatality,recurrent DKA has a major impact on the quality of life of patients and many factors can be  associated with it.

Objective:

  The aim of this study was to identify the factors that influence recurrent DKA  in the ED.

Methods:

  We carried out a prospective observational cohort study in patients who were hospitalized in the ED for DKA during four years (2012-2015) .The epidemiological data ,clinical signs, etiology and  treatment were studied. An univariate linear regression analysis was carried out to find out the variables associated with recurrent DKA.

Results :

  Inclusion of 176 patients.136 with type 1 diabetes and 40 with type 2 diabetes. Mean age was 34 +/- 16 years. Sex ratio = 0,81. The major clinical signs were vomiting (69%) and dyspnea (53%). The leading precipitating causes of DKA were the poor compliance with insulin therapy (44%) and  infection (42%). A total of 145 patients presented with the first time DKA and 31 with recurrent episodes. Compared with the first-time DKA patients, those with recurrent episodes were younger (27 ±13 years vs 35 ± 16, p=0,003),had type 1 diabetes (97 % vs 78 %,p=0,008), duration of diabetes less than 5 years ( 61% vs 54 %, p=0,02 ), had more hyperventilation (Paco2= 18 ± 5 mm hg vs 22 ± 7, p=0,004),and a short delay of visit to ED (39 ± 3 hours vs 66 ± 10 , p=0,008).

Conclusion:

  The younger age , a short delay of visit ED , a low Paco2 and duration of type 1 Diabetes less than 5 years  were associated with recurrent DKA .The recognition  of such factors and the institution of specific programs might reduce DKA recurrence .

Wided BAHRIA (TUNISIA, Tunisia), Hanene GHAZALI, Wided BOUSSELMI, Anware YAHMADI, Farah RIAHI, Mahbouba CHKIR, Monia NGACH, Sami SOUISSI
15:30 - 15:40 #8209 - OP054 Point of care Ultrasound for the approach to respiratory distress in pediatric age: a feasibility study.
Point of care Ultrasound for the approach to respiratory distress in pediatric age: a feasibility study.

Objectives

Point of Care Ultrasound (POCUS) in emergency medicine (EM) is a goal directed analysis integrated with the clinical examination of the critically ill patient presenting to the Emergency Department (ED). Its overall scope is to provide rapid dichotomous answers to questions that arise during the assessment to rule-in or rule-out the diagnosis. In adult the integration of chest US with a bedside  ecocardiography (ECHO) improves diagnostic accuracy of acute dyspnea allowing an appropriate management of the patient. There are no data available for its impact on pediatric patient management in the ED.

 Methods

This is a prospective, single center, observational study with the aim to verify the diagnostic performance and reproducibility of  POCUS evaluation including chest, heart, and IVC in the differential diagnosis of respiratory distress in children admitted to a pediatric ED, comparing this procedure with the standard approach in use. Moreover we want to estimate the time needed to complete POCUS assessment compared to the standard approach.

The study was leaded on a sample of patients aged 29 days to 18 years with respiratory distress, for whom two clinicians performed independent evaluations. We compared the diagnosis of the first clinician assessor with the diagnosis resulted by the POCUS approach performed by the researchers. The following outcome measures were used: 1) time to the diagnosis, 2) diagnostic accuracy of the two assessments, 3) concordance of diagnosis set with the two approaches with the gold standard. We considered as gold standard the discharge diagnosis from the ED, Observation Unit or ward.

 Results

During the enrollment period 579 patients with respiratory distress were evaluated in our ED. We enrolled 68 patients so this resulted in 511 (88%) missed eligible. The sample of the patients enrolled was similar to the missed eligible by age, gender and for the presence of risk factors. There were not significant differences between the average time needed for the standard clinical evaluation and for the POCUS examination (p=0.22). The average time for POCUS examination was significantly lower than the time needed to make a diagnosis in the subset of patients that underwent chest XR (p=0.02) and significantly lower than the time needed to obtain the discharge diagnosis from the ED or Observation Unit (p<0.05). The overall agreement of the diagnostic hypotheses compared to the gold standard was moderate for both POCUS (k =0.60) and the standard assessment (k=0.54). Finally for the patients who were admitted, we calculated the agreement between the diagnosis based on the standard approach and POCUS assessment with the discharge diagnosis that resulted respectively moderate (k=0.45) and perfect (k=0.85).

In patients who presented for wheezing, POCUS assessment showed a significantly higher specificity than the clinical evaluation alone (respectively 87% 95%CI 69.2-96.2 and 43% 95% CI 25.5-62.6, p <0.05).

Conclusions

Our study showed that POCUS evaluation is useful to address a more accurate and faster diagnosis of respiratory distress in children compared to the sole standard clinical approach. In the context of pediatric emergency medicine awareness is required to apply POCUS in clinical practice

Niccolò PARRI, Martina GIACALONE (Firenze, Italy), Elisa GUERRINI, Francesca BRONZINI
Room OP-SCHATZKAMMERSAAL
15:45

Monday 03 October

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PH3-S1
15:45 - 16:05

Poster Highlight Session 3 - Screen 1

15:45 - 15:50 #6454 - Analysis of Emergency Department Attendances and their Suitability for Primary Care: a retrospective observational study.
Analysis of Emergency Department Attendances and their Suitability for Primary Care: a retrospective observational study.

 There is a general feeling that work now undertaken by the Emergency Department (ED) at Aintree University Hospital, Liverpool, overlaps greatly with that of primary care. The reasons for this are multifactorial and are shared and recognised nationally. 1

 In a move to consider incorporating a primary care services alongside the ED in the future, a retrospective analysis was conducted to gain the evidence needed to support such a service. Current estimates are around 15-20% of ED attendances would be suitable for primary care.

 All attendances in March 2015 to Aintree University Hospital ED were analysed retrospectively from electronic notes.

 Those presenting between midnight and 8am, category 2 on arrival, admitted to specialties or who had sustained minor injuries were excluded from the initial potential GP criteria. *

 Correlation of the triage slip of those remaining with a robust, longstanding, potential GP suitable list, taken from our out of hours urgent care provider, was then assessed.**

 The GP suitable patients were then scrutinised for: age, gender, time of presentation, presenting complaint, investigations done and disposal.

All information was tabulated and analysed.

 

6908 attendances to Aintree ED in March 2015. 

663 patients were identified as GP suitable.**

 This represents on average:

            21 patients per day (range 11-39),

            32% of population with exclusions** (range 17-59%) and

            10% of all admissions (range 6-19%).

 Further analysis revealed:

            predominant age was under 40y

            male=female

            steady stream throughout the day 8am until 12pm

            most common presentation was non traumatic joint or back pain and upper respiratory tract symptoms

            investigations were completed on 2/3 of patients, 2/3 of which did not change management on objective review.

            99% of patients were discharged home

The study confirms the significant amount of primary care work taken on by our ED.

10% of all admissions is slightly less than expected, however, this still represents a large proportion of daily work. 1

The list used to assess GP suitability was thought to be conservative. The true figure may be higher than shown.

The evidence generated is sufficient to warrant a business plan to co-locate primary care with our ED. 32% reduction walking majors patients or 10% reduction of all attendances could dramatically decrease the workload.

 

 

*population with exclusions ( ie, Those presenting between midnight and 8am, category 2 on arrival, admitted to specialties or who had sustained minor injuries)

 

**GP suitable criteria:

  • Sore eyes
  • Ear pain
  • Sore throat
  • Neck pain
  • Viral illness, coryza, coughs and colds, well chest infection
  • Chronic/mild abdominal pain, constipation, diarrhoea, gastritis
  • Non traumatic back or joint pain
  • Urinary symptoms
  • Gynae symptoms
  • Rashes, bunions, in-growing toenails
  • Moles, lumps, bumps

 

References:

 

  1. STEP campaign: RCEM’s steps to rebuilding emergency medicine. Royal College of Emergency Medicine, 2015.
Karen SQUIRES (Liverpool, United Kingdom), Nicola HAINES, Laura MCGLYNN, Emma LYNCH, Helen RYAN, Jason NGUI, Rosalind HARRISON
15:50 - 15:55 #7039 - Violence against staff of emergency departments across south Trinidad.
Violence against staff of emergency departments across south Trinidad.

Purpose: The increase in incidence of violence aganist health care workers is a matter of great concern in developing societies across the globe.On a compartive basis the health care sector ranks highest as the target of workpalace violence.The present study was designed to identifiy the prevalence and extent of violence directed at emergency department staff across south Trinidad.

Methods/Materials: The investigation was conducted in five emergency departments across South Trinidad.A questionnaire was designed based on guidelines from earlier studies obtained through literature search. It was modified to suit local practices and used as a tool for collecting data from 131 staff working across various emergency settings at various professional levels. The study sample and occurence of violence were charcterized with the help of descriptive statistics.

Results:The study revealed 87.8% of the participating staff had been subjected to violence ,but only 43.1% of the cases had been reported.76.9%of the sample were ignorant about saftey policies, and 84.9% of them had never received training in handling of violent patients.

Conclusion:The present study brought to light the fact that healthcare workers faced a high risk of violence and abuse, but lacked the skills and knowledge to deal with such situations.Every health facility must take protective measures like increasing security,and should adopt stringent measures to punish the offenders.

Sriram NALLAMOTHU (SAN FERNANDO, Trinidad and Tobago), Kavitha DUGGINENI, Rishi RAMTAHAL
15:55 - 16:00 #7690 - Impact of refugee presentations on the case-load of a medium-sized German emergency department (ED).
Impact of refugee presentations on the case-load of a medium-sized German emergency department (ED).

Introduction:
Alone in 2015 Germany saw in influx of approximately 1.1 million refugees. German immigration authorities mandate, that refugees receive the amount of medical treatment sufficient to avert dangers to life and limbs and remove any immediate health threats to themselves or the German public. However, the delivery of medical services to refugees in Germany is heterogenous and relies heavily on local health policy and indivual volunteer health care workers. As a result, the general feeling is that many refugees seem attend their local emergency department (ED) for emergent, urgent and non-urgent medical conditions alike on a 24/7 basis. It is also felt, that refugees require a disproportionate amount of ressources due to language barriers and special cultural needs. Aim of this retrospective case note study was therefore to evaluate the real impact of refugee presentations to the case-load and consequently work-load of a medium-sized German ED.

Methods:
We conducted a retrospective case record review of all refugees presenting to the ED in the first three months of 2016. The following data were recorded: type of emergency (trauma/surgical, medical/neurological, paediatric, obstetric/gynaecological), patient age and disposition (inpatient/outpatient). Secondly we looked at the presenting complaint/main ED diagnosis in order to gauge whether an ED attendance, out-of-hours (OOH) or next-day general practitioner (GP) visit would have been appropriate. 

Results:
According to the latest census, the County of Lippe has a population of 353.000 residents. Of these, we recorded around 13.000 ED visits during the study period. This compares to 669 refugee ED visits on the background of around 4.500 refugees and asylum-seekers living in the County of Lippe. Approximately 70% of refugees were male with 30% being female. 33% of refugees attended because of a medical/neurological condition, 29% with trauma or surgical conditions, 28% were unwell children whereas 10% sought help for pregnancy-related concerns. Most refugees attending could be discharged from the ED (65%). This compared favorably to an overall ED discharge rate of 51% for the resident population during the above study period. Going by the presenting complaint/main diagnosis 35% of refugee ED visits were deemed emergencies, 19% where classified as urgent, whereas 46% could have seen a GP or office-based consultant the following working day.

Discussion:
This study is the first to describe the real impact of refugee attendances to the overall case-load of a medium-sized German ED. We believe our data to be representative, as the regional refugee distribution in Germany is governed centrally by fixed quotas depending on the relative population size and density. Our data suggest that refugees in transit present less often to the local ED than the sedantry local population and account for no more than 5% of overall ED visits. Compared to the sedantry population most refugees can be discharged from the ED, indicating a larger proportion of minor complaints suitable for an OOH- or GP-setting.

Patrick DISSMANN (Detmold, Germany), Felix KOEHRING, Florian FISCHER
16:00 - 16:05 #7839 - Job satisfaction among emergency department staff.
Job satisfaction among emergency department staff.

OBJECTIVE: To compare the level of job satisfaction (JS) among physicians (P), nurses (N) and administrative staff (AS) in an Emergency Department (ED). To analyze the relationship of JS with the demographic and professional characteristics of these personnel.

METHODS: We performed a descriptive, transversal study based on the answers to the Font-Roja questionnaire on JS voluntarily given by P, N and AS. Multivariate analysis determined the relationship between the overall JS and the variables collected. We also compared the dimensions of JS among P, N and AS.

RESULTS: A total of 22 P, 22 N and 30 AS were included. AS were significantly more satisfied than P and N: 3.42 + 0.32 vs. 2.87 + 0.42 and 3.06 + 0.36, respectively. Multivariate analysis showed the following variables to be associated with JS: rotation among the different ED acuity levels (OR: 2.339; confidence interval (CI) I95% 0.929-5.888) and belonging to AS (OR: 0.271; CI95% 0.093-0.796). P and N reported greater stress and work pressure than AS and described a worse physical working environment. Interpersonal relationships obtained the highest score among the 3 groups of professionals.

CONCLUSIONS: JS of P and N in an ED is lower than that of AS with the former perceiving greater stress and work pressure. Conversely, interpersonal relationships are identified as strength. Being P or N and not rotating among the different ED acuity levels increase dissatisfaction.

Miquel SANCHEZ (Barcelona, Spain), Montse SUAREZ, Maria ASENJO

Monday 03 October

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PH3-S2
15:45 - 16:05

Poster Highlight Session 3 - Screen 2

15:45 - 16:05 #7219 - “Is less really more?” Out patient antibiotic treatment (OPAT) in the paediatric emergency department (PED).
“Is less really more?” Out patient antibiotic treatment (OPAT) in the paediatric emergency department (PED).

AIMS: To describe the population of paediatric patients attending a tertiary Paediatric Emergency Department (PED) on an ambulatory basis for intravenous ceftriaxone following the introduction of a  formalised OPAT protocol from September 2015. Included in the analysis are patient demographics, reason for treatment, number of doses of antibiotic, investigations performed, admission rates and complications of OPAT.

METHODS: Data were retrospectively identified from the OPAT database which all patients treated were included on and patient electronic records analysed by the lead author.

RESULTS: 72 patients with a median age of four years (range two months – 14 years) from September 2015 until March 2016 were treated with OPAT.  54% were male. 169.5 doses of IV ceftriaxone were administered (mean 4.6, median 2). More patients received OPAT on Fri-Sun than the other weekdays and there was a peak in activity in February/March reflecting departmental overall attendance trends. The largest diagnostic group treated were patients with limb or trunk cellulitis (44%) followed by periorbital cellulitis (29%), lymphadenitis (13%) and other (14%). 67 of the 72 patients had a documented temperature in the electronic record, of which 12 (18%) were >37.5oC. Over 97% of patients had baseline full blood count and C-reactive protein at presentation, 53% had a blood culture and 75% had other microbiological or virology laboratory samples taken. There were 22 positive results from these, including one positive blood culture (streptococcus pneumoniae), five group A streptococcal swabs, five staphylococcus aureus swabs and smaller numbers of other bacterial and viral pathogens.  49% had imaging, mostly ultrasound scans.  16 patients (22%) were subsequently admitted, of whom 69% were male. Of these, seven patients had cellulitis, five periorbital cellulitis, one tenosynovitis, one abscess, one lymphadenitis and one occult bacteraemia. Most were admitted for worsening appearance and no children were systemically septic or unwell. Admission rates in the febrile versus non febrile groups were not significantly different (25% versus 21%). 50% of the patients admitted required surgical intervention in the form of incision and drainage or washout. One child had an orbital cellulitis after 24 hours OPAT and an uneventful drainage of this. Another had a calcaneal osteomyelitis and subsequently developed a subtalar septic arthritis. The remainder had a change in intravenous antibiotics and were in-patients for up to 48 hours.

CONCLUSIONS:  OPAT with IV ceftriaxone is an alternative to hospital admission in well children with predictable pathologies.  In our population of 72 patients, 78% of patients were successfully managed in this way, thus reducing bed stays aswell as emotional and physical inconvenience. Those that were admitted had complications unforeseen at the outset of treatment but were predictable of the primary disease process and clinically recognised with appropriate escalation of care. Caregivers of children treated with OPAT must be counselled about the risk of complications and potential need for more frequent intravenous antibiotics or surgical intervention at the beginning of treatment so that their expectations can be adjusted accordingly.       

Jennifer Kate SMITH (Edinburgh, )
15:45 - 16:05 #7263 - Suggestion of a modified reduction maneuvers with parents in the pulled elbow children.
Suggestion of a modified reduction maneuvers with parents in the pulled elbow children.

Introduction

If radial head subluxation, otherwise known as pulled elbow, occurs, closed reduction can diagnose and treat the child simultaneously. As the guardian seldom understands the maneuver without explanation, we revised a method to involve the caregiver in the treatment.

 

Method

This is a prospective controlled study. From January, 2014 to December, 2014, children suspected of radial head subluxation, under the age of 6, were enrolled. Patients were randomly assigned to two groups. One group was treated conventionally and the other group was treated whilst the parent’s finger was on the patient’s lateral epicondyle. A total of three attempts were made using hyperpronation method and the supination-flexion method. The physician then recorded whether the treatment succeeded, the number of attempts, easiness of the reduction, guardian’s degree of understanding and satisfaction.

 

Results

A total of 116 patients were enrolled. The number of attempts in the experimental group and the control group was 1.27 and 1.35 times respectively. The success rate was 96.6% in the experimental group and 94.7% on the control group. There was no statistically significant difference within the two groups. The physicians found the revised method as easy as the conventional method and the caregiver’s degree of understanding was higher in the experimental group.

 

Conclusion

As the revised method increases the degree of guardians’ understanding and does not increase the difficulty of the procedure, we recommend using the revised method in treating radial head subluxation.

Heeyoung KIM (Ilsan, Korea, Republic of), Junseok SEO, Hanseong LEE
15:45 - 16:05 #7522 - Differences in the paediatric population, diagnostics and outcome in emergency departments: a multicentre prospective observational study.
Differences in the paediatric population, diagnostics and outcome in emergency departments: a multicentre prospective observational study.

Background / introduction

 

Little is known about differences in diagnostics and therapy in pediatric emergency medicine (PEM).

The aim of this study was to assess differences in population, management and outcome of children in Europe. To our knowledge this is the first large European study covering this area.

These differences can be relevant when interpreting multicentre studies and can be used to improve clinical care.

                                                                                               

Participants and methods

 

This study is part of the TrIAGE project, a prospective observational study in five ED’s in 4 different European countries (the Netherlands, UK, Austria, Portugal). Data collection consists of routinely recorded patient data, automatically extracted from electronic medical records. Study sites are instructed in data collection and a minimum set of required variables. Data harmonization and quality checks were performed.  We included all consecutive children aged

                                                                                                                               

Results

 

84,747 children were included. Between the settings, populations differ in Manchester Triage System (MTS) urgency. Some centres have a more “high urgency” population (defined as MTS category 1,2 and 3) than others (range: 62.5 % urgent patents in the high urgency setting versus 27.4% in the low urgency setting ) and the rate of trauma- versus non-trauma-patients ranged from 4.7% to 50%.

 

Secondly, we saw differences in management, such as how often vital signs were measured (In 36% versus 78% of the cases at least 3 vital signs were measured) and how often diagnostic tests were performed (ranging from less than 8% to over 37%).

These differences were related to MTS urgency, age, gender, and trauma- versus non-trauma-patients. Admittance to hospital was  significantly associated with these aspects of management, even when corrected for the previously mentioned confounders.

 

Finally the centres differed in outcome measures such as general admission rates and combined IC admission rates and mortality. These differences remained after correcting for MTS urgency, age, gender, and trauma- versus non-trauma-patients.

                                                                                                                                                                               

Discussion/conclusion

 

Our data showed substantial differences in presentation, management and outcome exist in different European ED’s.

Some differences, such as admission rates, can be partly explained by differences in high-urgency versus low urgency settings or the ratio of trauma-patients versus non-trauma-patients.

However, significant differences remain even when correcting for these factors, showing that there seems to be a real and significant difference in population, management and outcome  between settings, or even countries.

We believe it is worthwhile investigating the causes of these differences in outcome. Aspects of influence could be patient comorbidity or local practice differences caused by culture and local guidelines.

More research is needed to clarify the causes and clinical significance of these differences.

Dorine BORENSZTAJN (Rotterdam, The Netherlands), Joany M ZACHARIASSE, Susanne GREBER-PLATZER, Claudio F ALVES, Paulo FREITAS, Frank J SMIT, Johan VAN DER LEI, Ewout W STEYERBERG,, Ian MACONOCHIE,, Henriëtte A MOLL
15:45 - 16:05 #7645 - Prediction of survival and neurological outcome in paediatric cardiac arrest.
Prediction of survival and neurological outcome in paediatric cardiac arrest.

INTRODUCTION.   Mortality of paediatric Cardiac Arrests (CA) remains high despite efforts towards its reduction, and survivors may have profound neurological impairments. Certain blood parameters (pH and lactate) and the Paediatric Logistic Organ Dysfunction (PELOD) score in 24 first hours have been described as predictors of worse outcome. There is however still a need for additional evidence in children as these parameters could then help to inform parents and to support decisions.

PARTICIPANTS AND METHODS.  Prospective study (65 hospitals, 6 countries) using Utstein style with paediatric Out-of-Hospital CA (OHCA) and Emergency-Department CA (EDCA) in patients admitted to Emergency Departments.  The association between first blood pH, first lactate and PELOD score in first 24 hours with survival and good neurological outcome to discharge (paediatric overall performance category –POPC– 1 or 2) was studied. Data collection from 1st June 2014 to 31st  March 2016.

RESULTS. We have analysed 101 CA, 14.9 % of which were EDCA. The median age of the sample was 3.6 years (range 0 - 17.2), 62.4% were male. The initial rhythm was asystole in 51.4% of CA, bradycardia in 22.8%, ventricular fibrillation in 6%, pulseless electrical activity in 4%, pulseless ventricular tachycardia in 3% and unknown rhythm in 12.8%.  

38 children survived to hospital discharged: 15 with POPC 1, 7 with POPC 2, 10 with POPC 3, 4 with POPC 4, 2 with POPC 5. 6 children are still inpatients or are missed patients.

 We found an association between survival to discharge and:

a) Higher blood pH (<0.001). Minimum venous pH in survivors, 6.67.

b) Lower lactate (p=0.006). Maximum venous lactate in survivors, 17.8 mmol/l.

c) Lower PELOD score in first 24 hours (0.003). Maximum PELOD in survivors, 63.

We found an association between survival to discharge with POPC 1 or 2 and:

a) Higher blood pH (p=0.007). The minimum venous pH in patients with POPC 1 or 2 was 6.70.

b) Lower PELOD score in first 24 hours (p<0.001). The maximum PELOD in patients with POPC 1 or 2 was 52.

Lower lactate was n.s. (p=0.088). Maximum lactate in patients with POPC 1 or 2 was 15.3 mmol/l.

      

CONCLUSION.  

Blood pH, blood lactate and PELOD in first 24 hours are good predictors of survival to hospital discharge in children after OHCA and EDCA. Nevertheless, only blood pH and PELOD score in first 24 hours seem to be adequate predictors of a good neurological outcome to discharge.

The worse values of theses parameters in survivors are so extreme that it is not easy to identify patients with no chance of survival.

Nieves DE LUCAS (Madrid, Spain), Jesús LOPEZ-HERCE, Patrick VAN DE VOORDE, Antonio RODRÍGUEZ-NÚÑEZ, Bob PHILLIPS, Rihanne OOSTENBRINK, Ian K MACONOCHIE, Edurne LÓPEZ, Niccolo PARRI, Sofia MESA, Nuria CLERIGUÉ, Benedicte LE ROUX, Rafael MARAÑÓN, Isabel DURÁN HIDALGO, Dušan VLAHOVIČ, Elena LENCE, Louis BEYSSAC, Deolinda MATOS, . PEDIATRIC CARDIAC ARREST STUDY GROUP

Monday 03 October

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PH3-S3
15:45 - 16:05

Poster Highlight Session 3 - Screen 3

15:45 - 15:50 #7094 - CPR RsQ Assist compared with Hands-only CPR in manikin model.
CPR RsQ Assist compared with Hands-only CPR in manikin model.

Background : Chest compression quality is a determinant of survival from sudden cardiac arrest. The CPR RsQ Assist is a new cardiopulmonary resuscitation device for hand-only chest compression.The aim of this study is to compate the CPR RsQ Assist with the standard hand-only compression in term of chest compression quality in manikin model.

method : 80 participants were included from medical student, emergency resident, nurse and paramedic in Ramathibodi hospital. Each participants were performed maximum 4 minutes hand-only compression with or without the CPR RsQ Assist device.During chest compression, quality parameters from manikin were recorded: compression rate, depth and incorrect hand position.

Result : Time to stop chest compression was significantly increased in CPR RsQ Assist device user compared with standard hand-only compression(222.93±36.53 VS 179.67±50.81 seconds; P < 0.001). The mean compression depth was not statistically significant different between standard compression with CPR RsQ Assist compression (56.42±6.42 VS 54.25±5.32; P=0.052). At the first and second minutes, compression rate was higher in standard compression (133.21±15.95 VS 108±9.45; P< 0.001 and 127.41±27.77 VS 108.5±9.93; P<0.001). No statistically significant different in percent of too shallow compression and incorrect hand position.

Conclusion : CPR RsQ Assist can help to reduce the fatique of rescuers to chest compression.The quality of the compression is similar to manual chest compression.

Chaiyaporn YUKSEN (Phavet, Thailand)
15:50 - 15:55 #7193 - Are the diagnoses of pre-hospital and hospital emergency physicians consistent? A prospective observational study.
Are the diagnoses of pre-hospital and hospital emergency physicians consistent? A prospective observational study.

Introduction: It is accepted that the pre-hospital emergency physician (EP), after examination and in the absence of serious conditions, can entrust a patient to a Basic Life Support Team transport (BLST) to reach the nearest Emergency  Department (ESD).

The aim of this study was to evaluate the diagnosis agreement between EPs and the hospital for these BLST patients and then verify the absence of deleterious effects of  BLST transport. 

Materials and methods: This was a prospective observational study, with a first aid chain quality approach. Inclusion criteria: patient over 18 years after examination by a EP was transported by BLST to an ED. Collected variables: age, gender, pre-hospital and hospital diagnosis, follow up (living, transferred or deceased on Day 1). A committee of three doctors ruled on the consistency of the pre-hospital and hospital diagnosis and then the relevance of the decision to transport by BLST and the adjustment of hospital referral. 

The primary endpoint was the diagnostic agreement between EPs and the hospital team . The Secondary endpoint were the rate of patients who needed to be transferred from ED to a specialized service, the rate of unexpected death. 

Results: From September 6 to October 27, 2015, 105 patients were included. Twenty-one  were lost to follow up. The median age was 55 [46-79] years, with 54 men (51.4%). The agreement rate between pre-hospital and hospital diagnoses was 61.9%.

The diagnostic discrepancy did not involve more transfers after arrival at ED (p=0.31). One patient died within 24 hours of admission to the ED.

Most often pre-hospital diagnoses were cardiological (n=47) and respiratory (n=14). Five  patients (4.7%) were transferred within 24 hours to an ICU. Seventeen cases were subject to review. Six had a discordant diagnosis. A posteriori, 5 patients out of 17 were subject to an inappropriate decision about the transport and/or hospital referral.

Discussion: Despite an intermediate rate of diagnostic agreement, the number of patients transferred secondarily was low and the death rate of less than 1%. Diagnostic discrepancy did not correlate to inadequate hospital referral of the patient.

Olivier YAVARI-SARTAKHTI (PARIS), Olga MAURIN, Daniel JOST, Stéphane BOIZAT, Paula VANHAECKE, Francois VIARD, Jonathan GONZVA, Sabine LEMOINE, Jean Pierre TOURTIER
15:55 - 16:00 #7248 - Prehospital use of lyophilized plasma for hemorrhagic shock: description of a randomized controlled study.
Prehospital use of lyophilized plasma for hemorrhagic shock: description of a randomized controlled study.

Introduction: Bleeding from trauma is responsible of a fall of clotting factors which maintains and promotes bleeding. Early plasma administration can correct post traumatic coagulopathy. Unlike frozen plasma which requires specific logistics only available at the hospital, lyophilized plasma is storable at room temperature, is recoverable in less than 6 minutes, and is compatible with all blood types, which allows its use in pre-hospital emergency situations. The aim of this report is to describe the protocol of a study that just started whose main purpose is to show the feasibility and effectiveness of using lyophilized plasma in pre-hospital situations for post traumatic hemorrhagic shock. 

Material and method: Randomized, open, controlled, multicenter study in two parallel groups. Inclusion criteria: severe trauma > 18 years with hemorrhagic shock [systolic blood pressure (SBP) 108] or shock index > 1.3. During prehospital care, patients receive either lyophilized plasma or saline in addition to the usual treatment applied in post-traumatic hemorrhagic shock.

First endpoint: variation of prothrombin time (PT delta) between pre-hospital care (before administration of lyophilized plasma) and hospital arrival (after lyophilized plasma). Secondary endpoints: 1. fibrinogen variation (F delta) between the pre-hospital and hospital admission; 2. Transfusion need during the first 6, 12, 24 hours of hospitalization; 3. Duration of intensive care unit stay; 4. survival at day 30; 5. Safety endpoint: description of accidents, incidents, events, and adverse events potentially related to lyophilized plasma. An ancillary study will compare the thromboelastometric (ROTEM®) parameters between the two groups. The number of subjects required is 70 per group for an alpha risk =0.05 and an 80% power. Statistical plans the intention to treat and per protocol analysis.  PT Delta, F delta and thromboelastometric data will be compared between the two groups by analysis of covariance. The transfusion need will be judged on the median amount transfused at the hospital: red blood cell concentrates, fibrinogen, FFP and platelet concentrates. Survival analysis will use the comparison between Kaplan Meier curves. Feasibility will be judged on the occurrence of technical or logistical problems encountered during the lyophilized plasma administration in prehospital setting. Safety will be judged on the occurrence of serious and unexpected adverse events attributable to lyophilized plasma.     

Discussion: This study should improve our knowledge on the effects of pre-hospital plasma transfusion for patients in hemorrhagic shock. 

Conclusion: The study started in 2016 with results expected in 2018.

Daniel JOST (Paris), Vincent LANOE, Benoit VIVIEN, Pierre-Yves DUBIEN, Jean Stéphane DAVID, Albrice LEVRAT, Dominique SAVARY, Sébastien BEAUME, Francois TOPIN, Marc FOURNIER, Francois KERBAUL, Pierre-Yves GUEUGNIAUD, Karim TAZAROURTE, Anne SAILLIOL, Jean Pierre TOURTIER
16:00 - 16:05 #7274 - Comparation between implementation of Croatian and Norwegian Emergency Call Index in EMCC.
Comparation between implementation of Croatian and Norwegian Emergency Call Index in EMCC.

Introduction

When someone calls the emergency number (112 or 194) in Republic of Croatia, the call is routed to the nearest Emergency Medical Communication Centre (EMCC). Based on the problem/symptoms/events presented EMCC dispatcher according to "Croatian Index of Medical Emergency Assistence" (Index) will decide about the level of response:red, yelow or green. A Red-response ("Red")is defined as an "acute", with the highest priority. The aim of these study was to analyse the "Red"patients and to compare results of using the Index in Croatia and Norway.

Methods

Analysis includes all "Red" interventions in the 19 EMCC during three month period in 2016., covering 3 318 921 inhabitants in Croatia (78%).Level of life-threatening condicions for the "Red" was based on the NACA score system. All data were collected from "e-Hitna" information sistem.

Results

During these period EMCC dispatchers received 163,484 phone calls. There are 122.801 calls in project .other were excluded for various reasons. 18,734 calls are marked as "Red priority", compared with NACA scoring from eRecords ( 19 191 patients). Croatian results were compared to Norwegian retrospective study.

The majority of the patients have a non-life-threatening situations: 70% of Red-response patients in Croatia and in Norwegian study (NACA 0-3). 24% of Red-response patients in Croatia were scored to be in a life-threatening situation (NACA 4-6). with 6% dead (NACA 7). In Norwegian study 25% Red-response patients were scored to be in a life-threatening situation. with 4% dead.

Red-response in Criteria Code (Criteria)"Chest pain" was used in 18% in both countries. Criteria "Inconclusive problem" was used in 20% (Croatia) and in 14% (Norway). Criteria "Unconscious>8 years" was used in 8% in both countries. Criteria "Traffic Accidents" was used 6% (Croatia) and in  7% (Norway). Often used Criteria in Croatia were also "Reduced consciousness" in 12 % and "Breathing problems" in 11%. In Croatia there is no Criteria"Ordered mission"which is used in Norway 18%. Criteria "Diabetes", "Back and abdominal pain" and "Accidents" werw used in 2-5% in both countries. 18 Criteria in Croatia and 19 in Norway were represented in less than 1%. 64% of all "Red" in Croatia were represented with 6 Criteria. 67% of all "Red" in Norway were represented with 5 Criteria.

Conclusion

Our study indicated that there is a high degree of similarities in the implementation of Index between Croatia and Norway. both in the scoring of Red-response patients and in the epidemiology of emergencies. Educational program for medical dispatchers is continious process under state control. Croatian Index is a tool used for the reception emergency calls and triage. allows the analysis of the collected data to improve outpatient emergency medicine. and also allows comparison with other countries that use it.

Reference

E.Zakariassen et al "The epidemiology of medical emergency contacts outside hospitals in Norway - a prospective population based study", Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2010

Ministarstvo zdravlja RH, Hrvatski Indeks prijema hitnog poziva, 2011

The National Commitee on Aeronautics (NACA)

Zavod za hitnu medicinu www.hzhm.hr

e-Hitna Rinels www.rinels.hr/ehitna.php

Jasna JANEŠ-KOVAČEVIĆ, Senka ŠTRBO (Rijeka, Croatia), Ana MARIČIĆ

Monday 03 October

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PH3-S4
15:45 - 16:05

Poster Highlight Session 3 - Screen 4

15:45 - 15:50 #4538 - Does Psyche Pain Manifest as Agitation in the Emergency Setting? A Pilot Study.
Does Psyche Pain Manifest as Agitation in the Emergency Setting? A Pilot Study.

 Objective- The objective was to determine a patient’s level of psyche pain when they present to an Emergency Department (ED) and whether there was a relationship between this psyche emergency Department and whether there was a relationship between this psyche pain and the patient’s level of agitation.

Methods – This was a prospective study using a convenience sample of 100 patients presenting to an ED with a psychiatric complaint. This study was conducted in an urban, inner city trauma center with 55,000 ED visits a year. After obtaining consent, a research fellow administered validated tools for assessing agitation, Brief Agitation Tool (BAM), Positive and Negative Syndrome Scale-Excited Component (PANSS), Agitation Calmness Evaluation Scale (ACES), Psychological Pain Assessment Scale, Mee-Bunney Psychological Pain Assessment – MBPPAS and a self-assessment of agitation at admission. SPSS version 22 was used for statistical analysis and the study was IRB approved.

Results-A total of 74 patients were enrolled at this time. The most ED diagnosis was depression, schizophrenia or bipolar disorder. Majority of the patients were African-American (59%), falling in the 25-44 year old age range (56%), 52% male and 48% female. Psyche pain as rated by MRPPAS as marked (18.9%) or moderate (67.6%). The self-reported tool demonstrated 20% none, 16% mild 21% moderate and 42% marked level of agitation. The agitation rating varied by the tool with the self-reported level of agitation having the highest correlation with level pf psyche pain (p<.05).

Conclusion-Psychiatric patient frequently present to the emergency department with a high level of psyche pain and high level of self-reported agitation. This correlation may signal the need to address a patient’s level of psyche pain and agitation early in the evaluation process. 

Zun LESLIE (Chicago, USA), Downey LAVONNE
15:50 - 15:55 #4539 - Comparison of Self-Administered Post Traumatic Stress Disorder Tool vs. Researcher Administered Tool in the Emergency Department.
Comparison of Self-Administered Post Traumatic Stress Disorder Tool vs. Researcher Administered Tool in the Emergency Department.

Objective:  The purpose of this study was to determine whether patients in the emergency department would utilize a self-administered posttraumatic stress disorder (PTSD) assessment and referral vs. a researcher administered tool to establish their level of risk for PTSD and seek assistance.

Methods: This was a convenience sample of patients,  consenting and assenting, 12 years and older, who presented with a non psychiatric illness, to a level one inner city adult and pediatric Emergency Department.   The survey, a validated four question PTSD self assessment and referral tool, was randomized so that half of the patients completed the survey on their own and half were assisted by research fellow in completing the survey. Those who screen positive on the tool were contacted one week later to determine if they have scheduled an appointment or were seen for a follow-up appointment.  This study was IRB approved.

Results:  A total of 299 participants completed the survey, half (149) of which were self administered. The total amount of participants who tested positive for PTSD was 35% (105).  Fifty in both groups tested positive.  There was a significant difference (.01) between those who self administered the tool and those who had the tool administered in relationship to whom was more likely to follow up with behavioral health referrals.   Of those that tested positive for PTSD symptoms,  only 20% (22) followed up with referrals, the majority of which had self administered the tool. Self-referral made contact (40) more frequent that those who were researcher administered (18).

Conclusions: These results reveal that 35% of the participants tested positive for PTSD.  Out of those that test positive only 20% followed up with referrals, the majority of which had self 

Zun LESLIE (Chicago, USA)
15:55 - 16:00 #7115 - Is capnometry helpful in children with bronchiolitis?
Is capnometry helpful in children with bronchiolitis?

Background: Acute bronchiolitis is the most frequent lower respiratory tract infection in infants. Only small subsets of patients develop severe disease resulting in hospitalization despite having no identifiable risk factors. There is still a debate as to the role of capnometry in assessing ventilation in children with acute respiratory distress, and bronchiolitis in particular.

Methods: This was a prospective, single blind cohort study in which children younger than two years presenting to the emergency department (ED) with bronchiolitis were included. Our primary outcome was the correlation between the end tidal CO2 (EtCO2) and the clinical decision of hospital admission and discharge. Our secondary outcome measure was the correlation of EtCO2 upon arrival to the ED and clinical measures of bronchiolitis severity. Finally, by using multivariate models, we looked for other parameters that could contribute to the prediction of illness severity.

Results: One hundred and fourteen children with bronchiolitis were evaluated. Their median EtCO2 upon arrival to the ED was 34 mmHg (range 24-65 mmHg). EtCO2 values upon admission or discharge were not statistically different among patients who were hospitalized and among those who were discharged from the ED. Among admitted patients, we found no correlation between capnometry readings at admission and number of oxygen desaturation days, nor with the length of hospitalization. Wang clinical respiratory severity score was found, by using multivariate models, to predict nasogastric tube need, oxygen desaturation days, and length of hospitalization.

Conclusion: Capnometry readings upon arrival to the ED did not predict hospital admission or hospital discharge eligibility. Among hospitalized patients, EtCO2 did not correlate with the evaluated disease severity measures. Wang score was found to be the most consistent predictor of significant outcomes.

Ron JACOB (Afula, Israel), Lea BENTUR, Itai SHAVIT, Fahed HAKIM, Riva BRIK
16:00 - 16:05 #7187 - RETROSPECTIVE ANALYSIS OF PROGNOSTIC EFFICIENCY OF COMPLETE BLOOD COUNT PARAMETERS IN PATIENT WITH PNEUMONIA.
RETROSPECTIVE ANALYSIS OF PROGNOSTIC EFFICIENCY OF COMPLETE BLOOD COUNT PARAMETERS IN PATIENT WITH PNEUMONIA.

OBJECTIVES: The primary objective of this study is to evaluate the prognostic efficiency of complete blood parameters . The secondary objective of this study is to evaluate the factors that effect the prognosis in patients with pneumonia. 

METHODS: In our retrospetive study, patients with pneumonia who are older than 18 years old and  who admitted Ege University Emergency Medicine Service between 01.01.12 - 31.12.13 were studied. Datas were acquired by using the hospital database. The patients who admitted after their treatment started in another health instutition, patients who are using drugs which effect blood cells, patients who have disease that effect blood cells, patients whose death data were inaccessible , and patients whose pneumonia diagnosis were not certain were excluded from the study. Datas were grouped and were registered at data forms. Datas were loaded to SPSS 20.0 program and analyzed.  

RESULTS: Median age of 970 patients who included the study were 72 (18-118). 63.9% of the patients were male. According to Pneumonia Severity Index (PSI), 71,2%(690)  of the patients were Stage IV-V and were required hospitalization, 28.8%(280)  of the patients were Stage I,II,III and were treatable as outpatients. According to CURB65 score, 39% (378) of the patients were at low risk (score 0 and 1) and 61% (592) of the patients were at high risk (score ≥2). It was found that 6.4%(62)  of the patients were died in first 24 hours, 13.4% (130) of the patients were died in first 48 hours, 13.4%(130)  of the patients were died in first week, and 17.6% (210) of the patients were died in the first month. In patients who admitted emergency service with atypical symptoms (e.g. abdominal pain, loss of conscience, impairment of  oral intake) were found statistically higher mortaliy (p<0,05) compared to the patients who admitted with typical symptoms (e.g. cough, sputum, dyspnea). Mortality were  statistically higher in patients who has at least 1 additive ilness (p<0,05). It was found that mortality were increased 1,036 (±0,011) times as rate of breath increase as 1/min, mortality were increased 2,070 (2,070-3,457) times if fever was <36°C or >40°C, mortality were increased 1,008 (±0,002) times as urea increase as 1mg/dl. It was found that gender, pulse rate, trombocyte count <150000uL, and CRP values were not independent risk factors that effect mortality. Analyzing complete blood count parameters, it was found that 30 day mortality were increased 1,033 (±0,015) times as RDW increase as %1. There were found no connection between lowness of heamoglobin, haematocrit and mortality. There were found no connection between trombocyte count, MPV value, PSW value and mortality. 

CONCULSION: CURB65 and PSI score distribuions of the patients included to our study were similar to the literature. It was found that increase of RWD value were related to mortality. Heamoglobin, heamatocrit, trombocyte, PDW, MPV values were found unrelated to mortality. There were not enough studies related to prognostic value of complete blood count parameters. It is required to study widescale researchs with healthy control groups.

Senem NEBİ (ANTALYA, Turkey), Murat ERSEL, Funda KARBEK AKARCA, Özge CAN

Monday 03 October

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PH3-S5
15:45 - 16:05

Poster Highlight Session 3 - Screen 5

15:45 - 15:50 #5029 - The scorpion envenomations in the emergency room of béja's regional hospital (tunisia).
The scorpion envenomations in the emergency room of béja's regional hospital (tunisia).

Background : approximately 2600 deaths caused by scorpion envenomation are recorded every year in the world. In the Mediterranean regions, these envenomations are not enough reported because of their usual benignity. Our objective was to study the features of the various grades of the envenomation, the potential severity of this pathology in the region of Béja, the treatment in our emergency room and the clinical evolution of the patients.

Methods : It was a retrospective study realized from 16/01/2012 till 25/11/2012 in the emergency room of the regional hospital of Béja. We included only a part of stung patients according to the availability of the clinical data collected from them.

Résults : 40 patients were included in the study. The median of age was 44,5 years. 88,9 % of the cases took place in rural zones. 33,3 % of the stings happened inside the houses. 15 % of the cases of scorpion stings took place in the morning between 05:00 am and 07:00 am, 17,5 % between 10:00 am and noon, 17,5 % in the afternoon between 4:00 pm and 6:00 pm and 12,5 % in the evening between 7:00 pm and 9:00 pm. The scarifications and/or the application of tourniquet were noted in 76 % of the patients. 60 % of the patients consulted during the first hour after the sting, 90 % consulted during the first two hours. In 51,7 % of the cases, the sting is located in the upper limb, in 41,4 % it is located in the lower limb. Moderate systemic manifestations of scorpion envenomation of the grade II were found in 80 % of patients. The most frequently reported were the sweating (40 %) and fever (45 %). The vomiting was noted in only one patient (5 %), as well as the rhinorrhea and tearing in another one (5 %). The priapism was not reported by any male patient. Non specific polymorphous changes of the ECG were noted in 62,5 % of the patients. One patient (5 %) was classified grade III, 75 % were classified grade II and 20 % were classified grade I. Only 15 patients (37,5 %) received the scorpion antivenom. The duration of the hospitalization was between 25 minutes and 17 hours, with a median of 1 hour 55 minutes. The evolution was favorable with clinical recovery of all the patients of our sample.

Conclusion : The scorpion envenomation is still a public health problem in the region of Béja. It concerns essentially the active adults of the rural areas, with a peak of frequency during September and October. The moderate systemic manifestations are often present with a potential of severity. The irrational and dangerous practices (application of tourniquet, scarifications) are still widely used by patients. The treatment remains unfortunately non-standardized, and it is variable according to the habits and the knowledge of the doctors which take care of the stung patients in the emergency room.

Jobrane MANSOURI (Tunis, Tunisia)
15:50 - 15:55 #7059 - The effect of alcohol consumption on patient survival after organophosphate poisoning.
The effect of alcohol consumption on patient survival after organophosphate poisoning.

Aim: Organophosphate (OP) intoxication remains a serious worldwide health concern, and many patients with acute OP intoxication have also consumed alcohol. Therefore, we evaluated the effect of blood alcohol concentration (BAC) on mortality among patients with OP intoxication.

Methods: We retrospectively reviewed records from 135 patients who were admitted to an emergency department for OP intoxication between January 2000 and December 2012. Factors that were associated with patient survival were identified via receiver operating characteristic curve, multiple logistic regression, and Kaplan-Meier survival analyses.

Results: Among 135 patients with acute OP poisoning, 112 patients survived (overall mortality rate: 17%). The non-survivors also exhibited a significantly higher BAC, compared to the survivors (non-survivors: 192 mg/dL, interquartile range [IQR]: 97–263 mg/dL vs. survivors: 80 mg/dL, IQR: 0–166.75 mg/dL; p < 0.001). A BAC cut-off value of 173 mg/dL provided an area under the curve of 0.744 (95% confidence interval [CI]: 0.661–0.815), a sensitivity of 65.2%, and a specificity of 81.2%. A BAC of >173 mg/dL was associated with a significantly increased risk of 6-month mortality in the multiple logistic regression model (odds ratio: 4.92, 95% CI: 1.45–16.67, p = 0.001). The Cox proportional hazard model revealed that a BAC of >173 mg/dL provided a hazard ratio of 3.07 (95% CI: 1.19–7.96, p = 0.021).

Conclusion: A BAC of >173 mg/dL is a risk factor for mortality among patients with OP intoxication.

Hee Cheol AHN (Anyang, Korea, Republic of), Young Hwan LEE, Park SEUNG MIN, Young Taeck OH, Ji Hun KIM, Moon Sik KIM
15:55 - 16:00 #7688 - Risk factors for intubation in pesticide poisoning in the Emergency Department.
Risk factors for intubation in pesticide poisoning in the Emergency Department.

Introduction: Acute pesticide poisoning is frequent in the Emergency Department (ED). It can be severe or even fatal. The management may require the use of intubation and the hospitalisation in the unit intensive care. Many  factors are correlated with the risk for intubation.

Objective: The purpose of our study is to evaluate risk factors of intubation for acute pesticides poisoning

Matherials and methods: it was a  retrospective study based on analysis of 73 consecutive patients in an emergency department,for 4 years .The epidemiological data, demographic features, circumstances, outcome,the nature of the offending product, timely care, clinical and laboratory signs, treatment and evolution were studied. To detect the possible relationship between two variables; correlations were used.

Results: Seventy three patients were enrolled.The average age was 27 ± 9 years, sex ratio=0,25. Women psychiatric history were noted in 8% of patients. The causes of poisoning were with suicidal intent in 92% of cases, and were accidental in 8% of cases. Chloralose was the most frequently implicated in 52% of cases and  organophosphates in 45% of cases. Most patients (57%) consults in the first hour. Muscarinic syndrome was present in 82% of patients and nicotonic  syndrome was present in 60%. The ventilatory support was performed in 28 patients (38%).  Several risk factors  for intubation were detected : the female sex (p=0,03), chloralose (p=0,03), tremor (p=0,01) and  hypersalivation (0,006).

Conclusion: In the Emergency Department, physians must be conscientious about potential pesticide danger. the female sex , chloralose, tremor and  hypersalivation are correlated with a high risk of intubation and intensive care unit (ICU) admission.

Wided BAHRIA (TUNISIA, Tunisia), Anware YAHMADI, Hanane GHAZALI, Wided BOUSSLIMI, Farah RIAHI, Aymen ZOUBLI, Mohamed MGUIDICH, Sami SOUISSI
16:00 - 16:05 #7820 - Characteristics of acute poisonings in catalonian emergency departments (intox-28 study).
Characteristics of acute poisonings in catalonian emergency departments (intox-28 study).

INTRODUCTION:

Accidental and intentional poisoning or drugs overdoses remains a significant source of morbidity and mortality. The objective of this study is to evaluate the epidemiological and toxicological characteristics of acute poisoning requiring Emergency Department consultation.

METHODS

Descriptive study of poisonings attended in 7 Emergency Departments of Catalonia attended the 28th of each month from  2013 to 2015.   Data affiliation , type and location of poisoning , toxic involved, administered treatment, psychiatric evaluation,  notification to court and destination were collected and statistical analyses were performed by using IBM SPSS statistics.

RESULTS

A total of 475 patients were included. The mean age was 38,62 years (STD 19,61) and 46,3% were female. Most patients were from Spain (64,8 %) followed by Western Europe (7,8%), Latinoamerica (6,5%), Magreb (3,8%), and Eastern Europe (2,7%).  The main causes were recreation(40,6%), attempted suicides(25,1%) and accidents(21,7%).  Alcohol poisoning was present in 226 patients (47,8%), drugs in 165 patients (34,7%), and drugs of abuse in 92 patients (19,4%).  Among medicine overdoses, benzodiazepines stands out (24%) and drugs, cannabis(7,6%), cocaine(6,5%) and amphetamines(2,7%). It was suicide attempt in 37,9% of patients,  and 36% had psychiatric history. Emergency psychiatric assessment was performed in 30,3% and notification to court was issued in 15,2% of poisonings. Regarding treatment, activated charcoal was administered in 12,6% of cases,12,2% antidotes, and gastric lavage was performed in 3,4%. Hospital admission was necessary in 12,5%, Intensive Care Unit in 1,3%, and Psiquiatric unit 6%.

CONCLUSION

Toxics most frequently involved in acute poisoning are alcohol, benzodiacepines and cannabis. Activated  charcoal is the method of gut decontamination most used in acute poisoning, and the gastric lavage was used less than 5%.

REFERENCES

Albert, M., McCaig, L.F., Uddin, S.   Emergency department visits for drug poisoning: United States, 2008-2011(2015) NCHS data brief, (196), pp. 1-8.  Dart, R.C., Bronstein, A.C., Spyker, D.A., Cantilena, L.R., Seifert, S.A., Heard, S.E., Krenzelok, E.P. Poisoning in the United States: 2012 emergency medicine report of the national poison data system(2015) Annals of Emergency Medicine, 65 (4), pp. 416-422.    Martin, C.A., Chapman, R., Rahman, A., Graudins, A. A retrospective descriptive study of the characteristics of deliberate self-poisoning patients with single or repeat presentations to an Australian emergency medicine network in a one year period (2014) BMC Emergency Medicine, 14 (1), art. no. 21

Albert MORENO DESTRUELS (TARRAGONA, Spain), Jesus GÁLVEZ MORA, Domingo RIBAS SEGUÍ, Francesc Xavier AVILÉS JURADO, Gilmar PUGNET, Doina SOLTOIANU
16:10

Monday 03 October

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State of the Art
Pain Management & Procedural Sedation

Moderators: Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada), Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, Germany)
16:10 - 16:40 Migraine - patient handling and treatment options. Carsten KLINGNER (Germany)
16:40 - 17:10 Acute Pain Management in the ED. Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada)
17:10 - 17:40 Regional blocks for dental trauma and facial lacerations. Andy NEILL (Doctor) (Dublin, Ireland)
Room A-FESTSAAL

Monday 03 October

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B24
16:10 - 17:40

Austria, Germany, Switzerland Invites
Diverse klinische Themen

Moderators: Harald DORMANN (Germany), Mathias ZÜRCHER (Switzerland)
16:10 - 16:40 Mildes Schädelhirntrauma. Dieter VON OW (Switzerland)
16:40 - 17:10 Allergische Reaktion. Dieter VON OW (Switzerland)
17:10 - 17:40 Urogenitale Notfälle. Beat LEHMANN (Switzerland)
Room B-ZEREMONIENSAAL

Monday 03 October

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C24
16:10 - 17:40

Philosophy & Controversies
P&C Geriatric

Moderators: Olivier GANANSIA (Chef de service) (Paris, France), Richard WOLFE (Boston, USA)
16:10 - 16:40 Screening and Detection of Delirium in Older patients: Are CAM-ICU, mCAM-ED, RASS, bCAM helpful in the ED? Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
16:40 - 17:10 Management of Acute Chest Pain in Older patients in the ED: Is there any differences with other patients? Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany)
17:10 - 17:40 Screening Instruments to Predict Adverse Outcomes in Older Patients in the ED: Is it feasible? Pr Abdelouahab BELLOU (Research) (Boston, USA)
Room C-PRINZ EUGEN SAAL

Monday 03 October

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E24
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Research
Resuscitation

Moderators: Wilhelm BEHRINGER (Director) (Jena, Germany), Michael HOLZER (Austria)
16:10 - 16:40 Cooling during cardiac arrest, what’s on the horizon? Michael HOLZER (Austria)
16:40 - 17:10 Strategies to Improve Cardiac Arrest Survival: A Time to Act. Lance BECKER (USA)
17:10 - 17:40 Resuscitation in the 24th century. David HÖRBURGER (Physician internal medicine) (St. Gallen, Switzerland)
Room E-GEHEIME RATSTUBE

Monday 03 October

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F24
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YEMD
EM in Extreme environments

Moderators: Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, Switzerland), Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, Belgium)
16:10 - 16:40 Emergency medicine in the Antartic: Ins and outs. Béatrice LAUDET (interne) (PARIS, France)
16:40 - 17:10 SAVE: Military Emergency Medecine management of multiple victims in extreme situations. Yann-Laurent VIOLIN (PARIS, France)
17:10 - 17:40 Mass casualties and emergency medicine in the Himalayas. Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, Switzerland)
Room F-RITTERSAAL

Monday 03 October

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G24
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Paediatric track
Major Incident Management

Moderators: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh), Pr Yehezkel WAISMAN (Director, Dept. of Emergency Medicine) (Petach-Tikva, Israel)
16:10 - 17:40 Workgroup Session.
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Monday 03 October

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OP24
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Oral Papers 24

Moderators: Jeffrey KEEP (London, United Kingdom), Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
16:10 - 16:20 #4506 - OP055 Intravenous Caffeine versus Intravenous Ketorolac for the Management of Moderate to Severe Migraine Headache in the Emergency Department; a Randomized Controlled Trial.
Intravenous Caffeine versus Intravenous Ketorolac for the Management of Moderate to Severe Migraine Headache in the Emergency Department; a Randomized Controlled Trial.

Objective: Ketorolac is a standard agent for abortive management of migraine headache in the emergency department (ED). The objective of this study was to determine if intravenous caffeine is as effective as intravenous ketorolac for the treatment of moderate to severe migraine headaches.

Methods: This randomized double blind clinical trial was conducted between January and December 2014 in two EDs in Tehran, Iran. Patients who met International Classification of Headache Disorders, 2nd edition criteria for migraine were enrolled. Based on an online random number generator, patients received 60 mg caffeine citrate or 60 mg ketorolac infused intravenously over 10 minutes. Visual analog scales (VAS) were used to measure pain at baseline and one hour and two hours after infusion. Therapeutic success was defined as improvement of 3 points on the VAS without requirement of rescue medication. A sample size calculation determined the need for at least 102 patients.

Results: 193 patients were approached for participation and 110 patients were randomized. 55 patients were assigned to each group of whom 75.5 % were women. Baseline pain scores were comparable between the groups. Therapeutic success after 60 minutes was achieved by 63.6 % of patients in the caffeine and 70.1% of patients in the ketorolac group (p=0.23). After 120 minutes, 87.3 % of the caffeine group and 83.6% of the ketorolac group achieved therapeutic success (p=0.49). Subgroup analysis did not reveal any association between age or sex and outcome.

Conclusion: In this multi-center, randomized double blind ED study, intravenous caffeine was as effective as intravenous ketorolac for first line abortive management of acute migraine.

Alireza BARATLOO (Tehran, Islamic Republic of Iran), Alaleh ROUHIPOUR, Mohammad Mehdi FOROUZANFAR, Saeed SAFARI, Benjamin WOLKIN FRIEDMAN, Ali ABDALVAND
16:20 - 16:30 #6480 - OP056 Predictive Performance of a Regression Model to evaluate clinical outcomes of Acute Low Back pain patients in emergency department.
Predictive Performance of a Regression Model to evaluate clinical outcomes of Acute Low Back pain patients in emergency department.

Background:

Low back pain (LBP) constitutes a challenging health problem which causes considerable socio-economic burden to healthcare system globally. Efforts have been focused on early prognostic assessment and stratification of LBP patients to matched interventions. Recently, the STarT Back Screening Tool (SBT) for back pain prognostic indicators has been developed to help initial decision making in primary care settings and has shown clinical and economic benefits. To our knowledge, SBT has not been used in the emergency department (ED) to assess LBP patients. In this study, we aim to create a regression model by integrating SBT, demographic and clinical variables and to evaluate its predictive performance for 6-month clinical outcomes of acute LBP patients presenting to the ED of a tertiary hospital in Singapore.

Methods:

A prospective observational cohort study was conducted. Eligible patients consulting ED doctors with acute LBP were invited to participate and administered the SBT at initial evaluation. Demographic information and LBP-related clinical characteristics were either gathered from patients’ case notes or self-reported by patients via telephone interview. The primary clinical outcome was pain score measured using the Visual Analogue Scale which was collected at baseline and at 6-week and 6-month follow-up. Treatment or referral of patients was at the discretion of ED doctors in line with current best practice. Prediction of pain score at 6-month was evaluated by using a multiple regression model which integrated independent variables including SBT score, demographics (age, gender, ethnicity, BMI, employment status) and LBP-related clinical characteristics (prior LBP onset, current LBP episode duration, pain score at ED, pain score at 6-week).

Results:

A total of 173 eligible patients were recruited, of which 19 patients were excluded from the analysis due to loss of contact in 6-month follow-up. Multicollinearity diagnostic analysis showed no correlation between independent variables of interest except for SBT overall and psychosocial scores (Pearson correlation=0.90). Therefore, SBT psychosocial score was not included in the model development in this study. The multiple regression model achieved R2 of 0.425 and adjusted R2 of 0.375, where pain score at 6-week (β=0.58), employment status (β=-0.12) and age (β=-0.10) were the three strong predictors among all the variables.

 Conclusion:

A regression model built by integrating SBT overall score, demographic and clinical variables has shown value in predicting 6-month pain score for acute LBP patients presenting to the ED. This study concludes that a predictive model is useful in determining the pain score at 6 months and early physiotherapy should be provided to high risk patients to avoid poor outcomes.

Sohil POTHIAWALA (Singapore, Singapore), Jiang BO, Jennifer LIAW, Mark LEONG, Celia TAN
16:30 - 16:40 #7628 - OP057 The quality of work life of young emergency physicians.
The quality of work life of young emergency physicians.

Introduction: Although the practice of emergency medicine can be meaningful and personally fulfilling, it can also be demanding and exhausting. Emergency departments (EDs) are a particularly stressful work environment. This can be explained by difficult work conditions including significant workload and psychological demand, a default of resources, and lack of support. It is probable that these characteristics impact young emergency physicians’ perceived quality of life and work life balance. Our aim, in this study, was to evaluate quality of life and work life balance of French young emergency physicians.

Methods: We conducted a cross-sectional, anonymous, online survey of quality of life satisfaction among young emergency medicine physicians in France. The survey, containing 32 items,  was distributed by email via the AJMU network (Association of young emergency medicine physicians). Burnout symptoms were measured using validated instruments. Because other burnout studies have focused on the presence of high levels of emotional exhaustion or depersonalization as the foundation of burnout in physicians, we considered physicians with a high score on the depersonalization or emotional exhaustion as having at least 1 manifestation of professional burnout. Satisfaction level with work-life balance was explored as well. Descriptive statistics of percentage, mean and standard deviation and odds ratio calculation were used to analyse the data.

Results: 475 physicians completed the questionnaire (response rate of 33,6%). The median age was 31.5 years old (SD=2.7), among those 55.4% were women. The median duration of practice in the ED was 3.2 years. On a scale of 1 to 10, the level of satisfaction with their work was 6.6 (SD=1.8). The level of satisfaction with their life outside the ED was 7.2 (SD=2), and with their work life balance was 5.7 (SD=2.1). Overcrowding was considered stressful for 72% of responders. The mean level of perceived consideration by others specialists was 4.1 (SD=1.74). Only 7% of the physicians considered working in the ED until their retirement.  52.6% considered transferring to general medicine if they stopped working in the ED. Working more than 48 hours per week and being a woman were associated with a higher risk of presenting symptoms of burnout with a respective OR of 1.8 [1.1; 2.9] and 1.9 [1.1; 3.2].

Discussion: Our study has several strengths. The large physician sample was drawn from a young emergency physician registry, and included physicians from across our country in all type of practices, settings, and environments. However, our study is subject to several limitations among which the response rate of 33,6% among physicians who received an invitation to participate in the study is lower than expected. It is however similar to those seen in this type of questionnaire studies.

Conclusion: These results show that the young ED physicians in our study have an overall good quality of life and a satisfying work life balance. The results of a larger study would yield a greater understanding of the factors associated with work-related quality of life and burnout in the ED.

Jennifer TRUCHOT (Paris), Anthony CHAUVIN, Alice HUTIN, Thomas LEREDU, Patrick PLAISANCE, Youri YORDANOV
16:40 - 16:50 #7647 - OP058 Prognostic value of SOFA score in a population of patients admitted in an Emergency-Department High-Dependency Unit.
Prognostic value of SOFA score in a population of patients admitted in an Emergency-Department High-Dependency Unit.

Aims: To evaluate the prognostic role of anamnestic variables and Sequential Organ Failure Assessment score (SOFA) in a population of patients admitted in an Emergency Department High Dependency Unit (ED-HDU).

Methods: ED-HDU is a clinical setting with a sub-intensive level of care, whose mission is to stabilize patients in order to prevent admission in Intensive Care Units (ICU); a maximum 48-hour ED-HDU length of stay is recommended. From June, 2014, we recorded all our patients in a standardized database; after 20 months, we analyzed the database in order to identify predictive parameters of an adverse outcome. To standardize comorbidity, Charlson index was calculated; SOFA score calculation was employed to evaluate organ dysfunction. The primary end-points were ED-HDU mortality and ICU admission.

Results: In the study period (June 2014-March 2016) we admitted 2300 patients, mean age 72±16 years (range 14-102; 5% aged ≤40 years, 22% aged 41-65 years, 38% aged 66-80 years, 34% aged >80 years), 53% male gender; Charlson index was 4±3 (range 2-15) and SOFA score was 2.4±2.6 (range 0-17). Final dispositions were: 733 patients were discharged to home, 1242 were admitted in an ordinary ward, 144 in a HDU, 138 in an ICU and 43 died.  Overall, we could stabilize and avoid a level of care increase in 86% of our patients. Compared with admitted patients, discharged patients were significantly younger  (69±16 vs 73±16 years, p<0.001) and had a lower Charlson index (3.9±2.3 vs 4.6±2.5) and SOFA score (1.0±1.3 vs 3.0±2.8 all p<0.001); 91% did not show any organ failure at admission, 89% did not have any infection (respectively vs 62% and 61% in admitted patients, p<0.001) and among the 82 patients with infection, 79 had not the criteria for sepsis or septic shock. Non-dischargeable patients were divided in three subgroups: patients admitted in ordinary ward or HDU (D1, n=1368), admitted in ICU (D2, n=138) and non-survivors (D3, n=43). D3 patients were significantly older than D1 and D2 patients (81±13 vs 73±12 and 73±16 years, both p≤0.01), had a higher Charlson index (D1: 4.5±2.5, D2 4.9±2.4, D3 6.4±2.9, p<0.001) and SOFA score (D1 2.7±2.4, D2 4.3±3.6, D3 9.8±3.8, p<0.001).  Presence of moderate to severe organ failure, involving up to two systems, increased significantly (D1 35%, D2 53% and D3 84%,  all p<0.001) in the aforementioned subgroups with increasingly worst prognosis, as well as proportion of patients with an infection at ED-HDU admission (D1 37%, D2 45%, D3 81%, p<0.001 D3 vs D1 and D2) and infection severity (sepsis/septic shock: D1 28%, D2 55%, D3 83%, all p<0.001). A multivariable regression analysis including age, Charlson index, SOFA score and presence of infection at ED-HDU admission  showed that only SOFA score showed an independent prognostic value  both for ICU admission (RR 1.21, 95%CI 1.13-1.29) and ED-HDU mortality (RR 1.76, 95%CI 1.57-1.96, all p<0.001).

Conclusions: ED-HDU carried out its own mission in the most proportion of admitted patients; a high SOFA score was the only independent predictor of a bad outcome. 

Federico MEO (Ascoli Piceno, Italy), Francesca CALDI, Rita AUDISIO, Caterina SAVINELLI, Valerio Teodoro STEFANONE, Lucia TAURINO, Francesca INNOCENTI, Riccardo PINI
16:50 - 17:00 #7771 - OP059 Emergency rooms in Germany: better than their reputation? Why do patients with lower treatment urgency visit emergency rooms (ER)? Results of a patient survey in central emergency department/unit at a specialized hospital.
Emergency rooms in Germany: better than their reputation? Why do patients with lower treatment urgency visit emergency rooms (ER)? Results of a patient survey in central emergency department/unit at a specialized hospital.

Every year, about 20 million patients in Germany visit emergency units or are transferred to emergency units by emergency services and general practitioners. The reasons why patients prefer ER as first touch point are diverse and have not been investigated systematically from the patient's perspective so far. As numerous studies have shown, a majority of patients visiting the emergency units required only outpatient emergency treatment. Moreover, the costs incurred in the ER are not covered. Apparently, the system of physician’s emergency care established in Germany is not accepted by patients as intended.

In a hospital focusing on specialized care with 36,300 emergency patients per year, a patient survey was carried out in the central emergency department to investigate the reasons why patients visit the ER and do not use the provided outpatient care structures.

Study Design:
In the Central Emergency Department, an initial assessment by MTS (Manchester Triage System) was carried out with all patients who did not have an immediate doctor contact.
The survey period lasted 4 months, the questionnaires were issued to each patient with MTS category green or blue. The survey was anonymous and participation was voluntary.


In addition to the reasons for the idea and sociodemographic data were collected on a voluntary basis. The return rate of questionnaires was 10.7%.


Results:
57.5% of respondents were older than 40 years. From all respondents of MTS categories green and blue, 40.6% rated themselves a minimum to average life-threatening emergency. 52.7% of respondents had not been previously treated by a doctor. 70.1% have presented themselves in the ER. The 3 main reasons which led the patient to visit the emergency department:
1. "I think I'm getting better care in the ER (get all necessary investigations)" - 39.4%;
2. "I think the first point is the hospital" - 19.1%;
3. "The period when domestic / Specialist by a deadline takes too long" - 17.1%.

The survey results clearly express the view of the patients and can lead to a better understanding of the reasons why ER are visited in hospitals. Despite long waiting times, particularly for patients with low treatment urgencies, patients place the hospital emergency first in 60% of the cases. The own feeling as an emergency is more pronounced in the patients, as it is expected by the triage level. The statements of the patient in the survey can be regarded a representative sample as usual sociodemographic factors of the survey (age distribution, presentation days / times / Education) reflect the usual clientele of patients in the ZNA.
Thus, the expectation of the patients should be taken care of, and the in-hospital emergency care in Germany should be strengthened. It remains open to what extent, for example, information campaigns on the supply system in Germany can lead to a reduction of the treatments of patients in emergency rooms.

For the patient, a timely and customized emergency care appears to be important. Professional societies and politics in Germany will need to take care of this.

Bernadett ERDMANN (Wolfsburg, Germany)
17:00 - 17:10 #7816 - OP060 Intranasal Sufentanil versus Intravenous Morphine Sulfate in Pain Management of Patients with Extremity Trauma.
Intranasal Sufentanil versus Intravenous Morphine Sulfate in Pain Management of Patients with Extremity Trauma.

Introduction: Pain is one of the most common complaints of patients referred to emergency department (ED) and its control is one of the most important responsibilities of the physicians. The present study was designed, aiming to compare the efficiency of intranasal sufentanil and intravenous (IV) morphine sulfate in controlling extremity trauma patients' pain in ED. Methods: In the present clinical trial, extremity trauma cases referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2014 to March 2015 were randomly divided into 2 groups treated with intranasal sufentanil (0.3 μg/kg) and IV morphine sulfate (0.1 mg/kg) single-doses. Demographic data and information regarding the quality of pain control such as pain severity before intervention and 15, 30, and 60 minutes after intervention, and probable side effects were gathered using a checklist and compared between the 2 groups. Results: 88 patients with the mean age of 35.5 ± 14.8 years were included in the study (81.8% male). 44 patients received IV morphine sulfate and 44 got intranasal sufentanil. No significant difference was detected between the 2 groups regarding baseline characteristics. In addition, there was no significant difference in the groups regarding pain relief at different studied times (p = 0.12; F = 2.46; df: 1, 86). Success rate of the drugs also did not differ significantly at different studied times (p = 0.52). No significant difference was seen between the groups regarding side effects (p = 0.24). Conclusion: Based on the results of this study, it seems that intranasal sufentanil has a similar effect to IV morphine sulfate in rapid, efficient, and non-invasive pain control in patients with traumatic extremity injuries.

Ali ARHAMI DOLATABADI (Tehran, Islamic Republic of Iran), Memary ELHAM, Hamid KARIMAN, Majid SHOJAEE
17:10 - 17:20 #8128 - OP061 Sedation with nitrous oxide (N2O) in children, a clinical guide to implementation and use in everyday practice.
Sedation with nitrous oxide (N2O) in children, a clinical guide to implementation and use in everyday practice.

Introduction – In the emergency department (ED) and pediatric department (PD), minor procedures in children are often challenging due to anxiety and lack of cooperation by the child. Nitrous oxide (N2O) seems a suitable agent for procedural sedation (PSA). It has a rapid onset and offset, no fasting period is required and self-administration is possible. Although safety and efficacy were proven in international literature, PSA with inhaled N2O is only minimally used in Dutch hospitals. In this study we describe the implementation of procedural sedation with nitrous oxide in our hospital in a two year cohort.

 Methods –  All patients that underwent procedural sedation (PSA) with N2O (50%) in the emergency and pediatric department were retrospectively identified. Data on patient characteristics, type of procedure, depth of sedation and adverse events were recorded. PSA was performed using standardized pre-sedation assessment, monitoring during procedure and post-sedation discharge criteria. Concomitant use of systemic analgesia was contra-indicated. All medical staff was trained according to protocol, this included theoretical background training and supervision during the first five procedures. Knowledge of advanced life support was required. PSA could be executed by a well-trained nurse without supervision of a doctor. 

Results – During 2014 and 2015, 202 patients received PSA with inhaled N20, 48 patients were excluded due to missing data. 154 patients were included in this study. These were 86 boys and 68 girls with a mean age of 6,6 years (SD 3.9 years). Sedation was successful in children from the age of two years old. Procedures in which sedation was used; wound care (N=106), venous access (N=25), reduction of fracture (N=15), lumbar puncture (N=4), the administration of a plaster cast (N=2) and placement of a urine catheter (N=2).

97,4 percent of children had an ASA classification score of one. Mean duration of procedure was 17 minutes (SD 9,8 minutes).

Most reported side effect was laughing (N=57).There were no reported major adverse events. There were 16 reported cases in which comfort and suppression of anxiety during PSA were inadequate and the patient was uncomfortable during the procedure. There were seven reported cases in which the procedure could not be successfully completed. One procedure had to be aborted due to malfunction of  equipment. The other six procedures included; stitching of wounds to the face (N=3), placement of a urine catheter (N=2) and reduction of an incarcerated inguinal hernia (N=1). These procedures are known to be unpleasant and painful, especially in young children.

Conclusion– Sedation with nitrous oxide is safe, feasible and effective for both patient and medical staff in minor procedures in the emergency and pediatric department. In the vast majority (96.1%), sedation was successful. In more painful procedures, sedation without concomitant analgesia proved to be inadequate (N=6) and procedures could not be completed. For this reason the use of concomitant systemic analgesia with opiates was included in our protocol in 2016. Implementation of procedural sedation with N2O requires adequate training of medical staff and a close collaboration between the emergency and pediatric department.

Naomi PETERSEN (Amsterdam, The Netherlands), Femke GRESNIGT
17:20 - 17:30 #8201 - OP062 Factors associated with the development of chronic pain in trauma patients.
Factors associated with the development of chronic pain in trauma patients.

Introduction: In Canada, trauma injuries represent almost 200,000 hospital admissions per year. Depending on the type of trauma and other risk factors, a good proportion of patients will eventually develop mild to severe chronic pain. Fortunately, the early use of some treatments appears promising to prevent chronicity of post-traumatic acute pain. However, the research allowing the early identification of the subpopulation of trauma patients that may develop chronic pain is scarce and limits our capacity to test these preventive approaches.

Objective: To identify factors available at hospital admission associated with the development of chronic pain in a population of trauma patients.

Methods: In a cohort study performed on a registry of prospectively acquired data, we have included all patients 18 years and older admitted for injury in any of the 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Patients who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma were compared to patients who did not meet those criteria. Patients with a follow-up period lesser than 1-year and those with multiple trauma episodes were excluded.

Results: A total of 90 479 patients were retained. Mean age was 59.3 (±21.7), 53% were men, and the mean follow-up was 4.8 years (±2.4). The major causes of trauma were: falls (63%), motor vehicle accident (22%), as well as penetrating and blunt injuries (9%). We have identified 6172 patients (6.8%; 95CI:6.6%-7.0%) who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma. After controlling for confounding factors, the variables that were associated with the development of chronic pain were: spine injury (OR=2.3; 95CI: 2.1-2.4), loss of consciousness (OR=1.7; 95CI: 1.5-2.0), nerves damage (OR=1.7; 95CI: 1.5-2.0), history of depression (OR=1.5; 95CI: 1.3-1.6), history of alcoholism (OR=1.4; 95CI: 1.2-1.7),  head injury (OR=0.62; 95CI: 0.56-0.68), multiple trauma (OR=1.4; 95CI: 1.3-1.5), and being a female (OR=1.2; 95CI: 1.1-1.3). Receiving operating characteristic curves derives from the model was evaluated at 0.70.

Conclusions: Despite low incidence of chronic pain development found in our trauma cohort registry, several significant risk factors were identified. Hospital admission screening of the trauma population at risk of developing chronic pain will allow the early testing of preventive approaches.

Raoul DAOUST (Montréal, Canada), Jean PAQUET, Lynne MOORE, Jean-Marc CHAUNY, Sophie GOSSELIN, Jean-Marc MAC-THIONG, Marcel EMOND, Manon CHOINIÈRE, Gilles LAVIGNE
17:30 - 17:40 #8236 - OP063 Profesional practices concerning care limitations and end-of-life situation in an emergency department.
Profesional practices concerning care limitations and end-of-life situation in an emergency department.

Introduction: Emergency Departments (ED) are the front line of public health care system and are often confronted to end-of-life care. These situations are difficult and uncomfortable for patients, families as for medical staff. Leonetti law (2005) strengthened by Clayes Leonetti law (2016) forbids “unreasonable obstinacy” and frames decisions concerning means limitation or ending active therapeutic means. In this recent context, we wanted to assess professional practices concerning the decision making and medical management of end-of-life situations.

Material: We conducted a retrospective monocentric study from october 2015 to april 2016 in an ED of an academic hospital. Through medical charts, we included all patients that died in the ED or in the emergency hospitalization unit through the period and for whom a means' limitation decision had been taken.

Results: n=53 patients presented the inclusion criteria (0,1% of all visits). For 57% of these patients, the limitation decision wasn’t clearly written in the chart. 30% of these decisions were taken by a sole practitioner. In the first moments of their arrival in the ED, 28% of these patients had invasive yet inappropriate care. 55% of these patients were visiting the ED for the first time. 21% died in the first 4 hours after being admitted to the ED. We noticed wide heterogeneous pratices while managing dyspnea, pain, consciousness and sedation.

Conclusion: End-of-life situations are part of ED care. However care limitations are difficult decisions and are not easily and efficiently managed. Education is necessary for medical and paramedical staff in order to help those patients through these moments.

Guillaume FONS (Paris), Marie BALLESTER, Florence ATGER, Richard CHOCRON, Anne-Laure FERAL-PIERSSENS, Philippe JUVIN
Room OP-SCHATZKAMMERSAAL

Monday 03 October

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D24
16:10 - 17:40

EUSEM meets SAEM

Moderators: Andra BLOMKALNS (USA), Roberta PETRINO (Head of department) (Italie, Italy)
16:10 - 16:40 Quality and Safety Management in US Emergency Departments: Is there any improvement after the 15 years of "To Err is Human"? Andra BLOMKALNS (USA)
16:40 - 17:10 The evolution of academic Emergency Medicine in Europe. Roberta PETRINO (Head of department) (Italie, Italy)
17:10 - 17:40 Opioid drug abuse in the US: what is the role of the Emergency Department? Mark COURTNEY (Casuarina, Australia)
Room D-FORUM
17:40

Monday 03 October

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AWC
17:40 - 18:40

Award Ceremony

Moderators: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh), Pr Lisa KURLAND (speaker) (Örebro, Sweden), Youri YORDANOV (Médecin) (Paris, France)
Top Abstracts / Falck Prize / EBEEM Diploma Ceremony / EYSA / EuSEM Fellowships / EMDM / SimWars
17:40 - 18:40 #7244 - OP118 Efficacy and safety of methoxyflurane analgesia in adult patients in the emergency department: a randomised, double-blind, placebo-controlled study (STOP!).
OP118 Efficacy and safety of methoxyflurane analgesia in adult patients in the emergency department: a randomised, double-blind, placebo-controlled study (STOP!).

Background/Introduction

Acute pain remains highly prevalent in the Emergency Department (ED) setting1,2, with many patients undertreated3. Low-dose methoxyflurane, self-administered by the patient via a handheld inhaler (Penthrox®, 3mL dose) is a fast-acting, non-narcotic analgesic agent that has been used in Australia for 20 years. Data outside of Australia are limited, therefore this double-blind, randomised, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED setting.

 

Participants and Methods

Patients presenting to the ED with a pain score of 4-7 on the Numerical Rating Scale due to minor trauma (contusions, fractures, lacerations, etc) were randomised in a 1:1 ratio to receive methoxyflurane (up to 6mL) or placebo (normal saline), both via a Penthrox® inhaler. Study medication was self-administered by the patient as required by inhaling from the device. Rescue medication (paracetamol/opioids) was available immediately upon request of the patient.

 

The primary efficacy endpoint was visual analogue scale (VAS) pain intensity. Changes from baseline were analysed using repeated-measures ANCOVA. Treatment effects were estimated as least squares mean differences between the treatment groups overall (primary analysis) and at each timepoint. Key secondary endpoints were time to first pain relief and time to request for rescue medication (compared using Cox proportional hazards model) and rescue medication use (yes/no) within 20 minutes of the start of treatment (compared using logistic regression). All analyses adjusted for baseline VAS score.  Patients had a 14-day post-treatment safety follow-up.

 

Results

300 adult and adolescent patients were enrolled; data are presented for the adult subgroup (N=203). Mean baseline VAS pain score was ~66mm in both groups. Mean change in VAS pain from baseline to 5, 10, 15 and 20 minutes was greater for methoxyflurane (-20.7, -27.4, -33.3 and -34.8mm, respectively) than placebo (-8.0, -11.1, -12.3 and -15.2mm, respectively). Overall, there was a highly significant treatment difference (estimated treatment effect: -17.4mm; 95% CI: -22.3 to ‑12.5mm; p<0.0001). Median time to first pain relief was significantly shorter with methoxyflurane (5 minutes) compared with placebo (20 minutes) (hazard ratio: 2.32; 95% CI: 1.63, 3.30; p<0.0001). The proportion of patients who used rescue medication in the first 20 minutes was 2.0% for methoxyflurane and 22.8% for placebo (odds ratio: 0.07; 95% CI: 0.02, 0.29; p=0.0003). The proportion of patients requesting rescue medication at any time (prior to censoring) was lower for methoxyflurane (11.8%) than placebo (38.6%) (hazard ratio: 0.23; 95% CI: 0.12, 0.44; p<0.0001); median time to request could not be estimated. Treatment-related adverse events (mostly dizziness/headache) were reported by 42% of patients receiving methoxyflurane and 15% of patients receiving placebo; none caused withdrawal and the majority were mild and transient.

 

Conclusions

The results of this study support the evidence from previous trials that low-dose methoxyflurane administered via the Penthrox® inhaler is a safe, efficacious and rapid-acting analgesic.

 

References

  1. Cordell et al. Am J Emerg Med 2002;20:165–169.
  2. Berben et al. Injury 2008;39:578–585.
  3. Pierik JGJ et al. Pain Med 2015;16:970-84.

®: PENTHROX is a registered trademark of MDI Limited.

Frank COFFEY (Nottigham, United Kingdom), Patrick DISSMANN, Kazim MIRZA, Mark LOMAX
17:40 - 18:40 #7460 - OP119 Short-time variation in available beds predicts admission rate among chest-pain patients independently of high-sensitivity troponin t, seasonal and daily variation.
OP119 Short-time variation in available beds predicts admission rate among chest-pain patients independently of high-sensitivity troponin t, seasonal and daily variation.

Introduction: Chest pain is a common symptom at the emergency department (ED) which often leads to admission for further investigation. Assessment algorithms aim to safely reduce the rate of admission but it is unknown if the number of available beds at the time of admission decision affect admission rate or the risk of major adverse cardiac events (MACE) after discharge. Purpose: To investigate whether number of available beds was associated to admission rate or 30-day MACE among chest pain patients in the ED. Methods: This was an observational study at two EDs between 1st of January 2013 to 14th of September 2015. All patients >18 years with chief complaint chest pain and at least one high sensitivity cardiac troponin T (hs-cTnT) measurment were included. Information on number of available beds at the short-time emergency wards and coronary care units was extracted every five minutes and the average during a 30-minute period was calculated for each patient, two thirds into their stay at the ED, when the admission decision usually occurs. Association between number of available beds (one standars deviation increase) and admission rate, acute myocardial infarction (AMI) among admitted and 30-day MACE among discharged were studied with logistic regression together with sex, age, hs-cTnT>14 ng/L, ED site, season (winter as reference), visit-year (2013 as reference) and 24-hour variation (day, evening and night with day as reference). Results: Out of 24,730 patient visits, 6,873 were admitted out of which 1,134 were diagnosed with AMI. Among discharged, 70 patients had a 30-day MACE. The number of available beds varied in relation to the 24-hour period (p<0.001), season (p<0.001) and decreased yearly (p<0.001) during the study. Admission was independently associated to the number of beds (OR 1.11 CI95% 1.07-1.15), male sex (OR 1.52 CI95% 1.42-1.62), initial hs-cTnT>14 ng/L (OR 6.41 CI95% 5.93-6.94), age (OR 1.76 CI95% 1.69-1.83), year (OR 0.87 CI95% 0.81-0.94 for 2014 and 2015 respectively) and seeking the ED during spring or night (OR 1.15 CI95% 1.05-1.25 and OR 1.29 CI95% 1.17-1.43 respectively). AMI among admitted was more common among those with male sex (OR 1.48 CI95% 1.27-1.72), initial hs-cTnT>14 ng/L (OR 6.42 CI95% 5.38-7.65), seeking the ED during the evening (OR 0.82 CI95% 0.70-0.96) and 2015 as year of ED admission (OR 1.27 CI95% 1.06-1.51). Furthermore, initial hs-cTnT>14 ng/L (OR 7.01 CI95% 3.76-13.06), age (OR 2.45 CI95% 1.71-3.50) and male sex (OR 1.92 CI95% 1.15-3.21) were all associated to 30-day MACE. No relation between 30-day MACE and number of available beds was seen (p=n.s). Conclusions: The number of available beds was associated to admission rate idependent of other clinical information, including hs-cTnT, and may have affected the admission decision. No relation between available beds and 30-day MACE was seen. Further studies are needed on the causal relationship and optimal number of available beds for chest pain patients. 

Caroline JOHANSSON (Stockholm, Sweden), Anna PETTERSSON, Umut HEILBORN, Per SVENSSON
17:40 - 18:40 #8169 - OP120 Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?
OP120 Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?

Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?

Background: Large datasets from registries such as the Trauma Audit and Research Network (TARN) facilitates the development of risk estimation systems for these patient populations. An initial analysis of the probability of survival (PS12) risk estimation system in trauma patients enrolled in TARN at our institution demonstrated excellent discrimination in younger individuals with an area under the receiver operating characteristic curve (AUROC) of 0.94 (95% CI: 0.83 to 1.00). However, the ability of the system to estimate risk of short term mortality in older trauma patients was considerably lower with an AUROC of 0.64 (95% CI: 0.39 to 0.88).

Hypothesis: Risk estimation in older people could be improved through the incorporation of co-morbidity information.

Objective: To assess the improvement in performance of the system with the addition of co-morbidity information.

Study population: 869 major trauma patients enrolled in TARN at Saint Vincent’s University Hospital (SVUH), a tertiary referral urban university hospital, between Sept 2013 and Aug 2015.

Methods: PS12 estimates the risk of inpatient or 30-day survival in trauma patients based on Injury Severity Score (ISS), age, gender and Glasgow Coma Scale (GCS). The newer PS14 additionally includes co-morbidities, as a categorical variable defined by the number of co-morbidities present. PS12 and PS14 were calculated for each individual. Discrimination of each system was compared using AUROC. This was done separately for those aged under 65 years and those aged 65 years and over.

Results: In the 419 individuals aged under 65 years, both systems showed excellent discrimination with AUROC of 0.97 (95%CI: 0.94 to 1.00) for PS14 versus 0.96 (95%CI: 0.93 to 1.00) for PS12, p for difference = 0.23. In the 450 individuals aged 65 years and over, discrimination was significantly better in PS14 (AUROC 0.79 (95% CI: 0.70 to 0.88)) compared to PS12 (AUROC 0.71 (95%CI: 0.61 to 0.82)), p for difference <0.001. These findings were consistent when examining older age groups including those aged 75 to 84 years and those aged over 85. However, due to lack of power in some age groups, the differences did not reach statistical significance.

Conclusions: These results suggest that the current PS systems discriminate extremely well in younger people. It is unlikely that further refinements will result in meaningful improvements in risk estimation but may add complexity. For older individuals the addition of comorbidity has resulted in significant improvements. Further refinements including the addition of specific comorbidities, alcohol use and initial vital signs may yield further improvements in discrimination in this age group.  Simulated external validation, for example using 10-fold cross validation, may add further strength to these observations. 

Marie Therese COONEY, Dr John CRONIN (Dublin, Ireland), Justine JORDAN, Rachael DOYLE, David MENZIES
Room A-FESTSAAL
17:45

Monday 03 October

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E25
17:45 - 19:45

DGINA - General Assembly
Ordentliche Mitgliederversammlung der DGINA e.V. (Teilnahme nur für DGINA-Mitglieder)

Room E-GEHEIME RATSTUBE