Background:

The "One chance to get it right" national recommendations ⁽¹⁾ outlining an approach to end of life care replaced the Liverpool Care Pathway ⁽²⁾ in 2014. The Royal College for Emergency Medicine subsequently released best practice guidelines ⁽³⁾ for end of life care of adults in the emergency department. Our aim was to assess our performance in the recognition of patients nearing death, and the delivery of optimal end of life care, as measured in relation to this guidance. 

Method:

This was a retrospective case study carried out in a Scottish district general hospital. Our study cases included all patients who died within 24 hours of admission over the period 1/1/17 to 31/12/17 inclusively. Outcomes were chosen based on the five priorities of care ⁽¹⁾: recognition of the dying patient; communication; decision making; family involvement; appropriate utilisation of palliative medication.

Results: 57 patients met the criteria, of which 37% were male. The mean age was 77 years. The mean time from admission to death was 12.5 hours (range 3-24 hours). 82% were admitted from their own home, with the remainder from a nursing home or community hospital.  

The recognition that the patient was likely to die within hours was documented at initial assessment in 51% of cases. “Do not attempt cardiopulmonary resuscitation” (DNACPR) orders were documented in 81% of cases prior to death. This directive was in place prior to A&E arrival in 25%, with a further 24% documented during initial assessment. Discussions with patients/family were documented in 95% of cases. In 35%, these conversations were conducted by consultants. Specialist palliative care was involved in only 10% of cases, but palliative medications were administered to patients in 75% of cases (47% as bolus’, 28% as continuous subcutaneous infusions). Evidence of anticipatory care planning was present in 12% of cases, with preferred place of death documented in only 5%.

Conclusion:

The majority of patients in the study were recognised to be dying at first assessment, allowing maximum time for involvement in care decisions and for providing a comfortable and dignified death. Best practice is that DNACPR orders are documented prior to leaving the A+E department ⁽³⁾; this was only achieved in just under half of our patients. Communication is clearly prioritised, with 95% of cases having a documented discussion with patients/family; evidence suggests that this helps to minimise distress and aid the grieving process. Palliative medicines were prescribed in 75% of patients.  This may indicate an area where symptom driven prescription ⁽¹⁾ could be improved. Unfortunately, anticipatory care plans from both community and hospital were difficult to access in cases where they were noted to be available. In order for such plans to function optimally, they must be current and easily accessible.

Realistic medicine focusses on involving patients and their families in decision-making.  Nowhere is this more important than in end of life care. The implementation of these principles in the emergency department is critical to the success of this important and holistic approach.

Emergency Services are faced daily with the challenge of determining the location of incidences that are reported by using mobile telephones. In United Kingdom alone it is estimated that each year there are about 36.000 cases where a location could not be verbally provided by the caller and the Emergency Services have to spend a significant amount of time searching.

Since March 2016 the European Telecommunications Standards Institute (ETSI) which is an independent, not-for-profit, standardization organization for telecommunications in Europe, has published the technical report “Emergency Communications (EMTEL); Advanced Mobile Location for emergency calls”. Advanced Mobile Location (AML) allows use of native smart phone technology to pass location data from the handset directly to Emergency Services. In its simplest form AML is nothing but a 140 characters SMS that provides location information from the handset directly to the Emergency Services. The time to gather the location is 20 seconds. Mobile phones with Google Android operating system were the first to incorporate this and Estonia and United Kingdom were the first countries to utilize this technology to locate calls. Apple mobile phones have recently (March 2018) incorporated this into their operating system via the last update of their operating system. Having Google Android operating system and iOS operating system from Apple on board covers the vast majority of smart phones in the world today. Currently there are eight countries in the European Union (Austria (in 5/9 States), Belgium, Estonia, Finland, Iceland, Lithuania, Slovenia, UK) and New Zealand that have implemented this technology allowing the Emergency Services control rooms to have immediate access to the handset location of the caller.

Specific examples will be presented from real Emergency cases in the UK and Estonia that will illustrate the 4.000% increase in accuracy from network-based to handset-based caller locations. AML can provide a location precision as good as 5 meters outdoors from the handset (and averaging to within circular areas of ~25 m radius for indoor locations), a significant improvement on existing network cell coverage provided by mobile networks. Data from across the UK showed that network cell coverage had average circular areas of about 1,75 km radius.

In conclusion Advance Mobile Location has been incorporated in the Operating Systems of the vast majority of smartphones available in the world today and allows for increased precision in location, fewer questions about location and faster response to patients with life-threatening conditions. Nine countries in the world are already taking advantage of this technology to locate calls to Emergency Services and there are more currently in the testing phase. The majority of these countries are within the European Union. The implications for the clinical practice in the pre hospital environment are significant since by the definition of Emergency Medicine by EUSEM: “Time and timing in this setting may be critical either from a medical or from the patient’s point of view.”

Some evidence shows that a significant number of emergency physicians don’t apply mortality-related recommendations in the management of patient with major trauma. Looking for guidelines and systematic reviews, we evaluate the evidence in the literature to support an impact on mortality of some current clinical practices, namely five key points of the major trauma management: Advanced trauma life support (ATLS), trauma system, focused assessment of sonography for trauma (FAST), whole body computed tomography (WBCT) and viscoelastic hemostatic assays (VHAs). We found evidence showing that only some components of trauma system and WBCT have an impact on mortality in major trauma management. We also recorded a video simulating the management of a patient with major trauma aiming to point out the best evidence in the literature regarding whether the above five key points correlate with mortality. We propose this video as an educational tool to improve the awareness of emergency physicians regarding the best evidence supporting some current clinical practices in the management of patients with major trauma.

Background:

Analgesia and sedation are key elements of the care delivered by HEMS teams across the country. Adequate analgesia is important on humanitarian grounds, facilitates fracture reduction and may reduce blood loss. In circumstances such as entrapment, the use of analgesia and sedation may facilitate extrication and reduce time to definitive care.¹

Aim

Primary Objective: Compliance of monitoring during procedural sedation with current guidelines (ECG, NIBP, SO2, ETCO2)

Secondary Objective: Note any complications of sedation (Hypotension, Hypoxia, Bradycardia, CPR/ALS, Airway compromise, unplanned intubation)  

Methods

Retrospective database review using HEMSBASE of all procedural sedation using Ketamine and/or Midazolam from 01/01/2016 till 31/12/2016. 

Patients receiving these drugs as part of an RSI drug regimen, maintenance of anaesthesia or seizures were excluded.

Results

Total patients which met inclusion criteria: 141. The most common indications for sedation were fracture reduction (33%) and agitation (17%). 90% of patients had full observations recorded and this is a marked improvement from previous audit cycle (2009-2013: 27.8%, 2013-2015 56%). 51 patients (36%) had one or more complications following sedation, most commonly hypotension and hypoxia.

Conclusion

There has been a marked improvement in monitoring patients undergoing procedural sedation from previous audit cycles. The interventions which have led to this improvement include sedation sticker, KPI stickers/sedation checklist and the addition of ‘Sedation treatment modality’ onto HEMSBASE. To improve this further, a flagging system could be incorporated into HEMSBASE to alert clinicians to incomplete or abnormal observations. 

Finally, a number of clinicians felt it would be valuable to conduct a patient survey assessing the quality & depth of sedation being administered to patients. This avenue is currently being explored however, it poses challenges- namely around confidentiality & use of patient data.

Limitations

introduction
Pain in pediatric population is underestimated and not properly managed, especially in emergency department. In this study, we introduced the Pain Passport to pediatric trauma patients with suspected fractures presenting to the ED. The study aimed to evaluate the efficacy of the Pain Passport for improving the analgesic provision rate and time in the pediatric ED

Methods
This was a before-and-after study. We reviewed medical records of patients aged 3 to 18 years who were primarily diagnosed with fractures from May to August 2015. After introducing the Pain Passport, patients with trauma who presented to the ED were eligible for the study if they were aged 3 to 18 years and suspected to have fractures. 30 Patients were enrolled from May to August 2016. Researchers educated the enrolled patient and their guardian about using the Pain Passport. In both periods, information including demographics, analgesic administration rates, time intervals between ED arrival and analgesic administration, and satisfaction (5-point Likert scale) were obtained. The primary outcome was the difference in the analgesic provision rates between the two periods, and the secondary outcomes were the differences in the analgesic administration time between the two periods and patient or guardian satisfaction in the after period.

Results
Before the Pain Passport 202 eligible children were identified and after introduction of the Pain Passport, 30 children were enrolled. Epidemiological characteristics of both groups are similar. Before the Pain Passport, 40(19.8%) patients were given analgesics while after the Pain Passport 25(83.3%) patients were treated with analgesics, which is significantly more. The median time to spent until the administration of analgesics were 94(53-161)min in the before group while 38(24-60)min in the after group, which is significantly shorter. The median satisfaction score of the After group is 4(IQR, 3-5). The multivariate logistic regression analysis was done. The crude OR (95% CI) of the After group for the provision of analgesics was 19.52 and the adjusted OR for age, gender, initial pain score, diagnosis category and injury mechanism was 17.05. No side effects of administered analvesics was reported.

Discussion and Conclusion
This study implied that the patient-centered pain scoring by the Pain Passport can favorably alter pain management in the emergency department. Only few studies have reported on patient-centered pain scoring before, and reporting and understanding the pain experience from the patient's perspective is new, thus requiring further research.

Background:  The Centers for Disease Control and Prevention estimates that 385,000 sharps-related injuries occur annually among health-care workers. An international needle-stick injury reporting group estimated that 50% of these occur during the use of a device and 20% occur while suturing. Studies have shown that staples are comparable to sutures for securing central lines. Following a number of provider injuries during arterial line suturing, we decided to investigate the use of sutures versus staples for securing arterial lines.

Methods:  This is a prospective, observational study at an academic medical center. A convenience sample of emergency medicine resident physicians was enrolled.  Participants secured femoral arterial lines in a cadaveric model by suture and staple. We measured the time required to secure the line by each method. Participants were surveyed before and after placement seeking practitioner perceived: ease, safety (to operator), efficacy and speed on a Likert type scale. Preference method was solicited on post survey.  Operators were allowed to choose straight or curved suture needles in accordance with their usual practice pattern. A single staple device was provided.

Results: 24 subjects enrolled across all post graduate years. No injuries were observed. Stapling was significantly (p<0.001) faster than suturing with mean difference 45.8 seconds (95%CI 31.3-60.4). Subjects reported staples were more difficult (p= 0.0003) and less effective (p=0.01) following the exercise. However, there were no differences were measured in perception of operator safety (p= 0.34) or time required (p=0.68).  There was no clear securement preference across the group.

Conclusions: We hypothesized that post exposure, operators would report greater ease, safety and speed using staples.  While stapling was in fact faster, operators did not perceive it to be. Also, they reported stapling to be more difficult and less efficacious without the benefit of added safety. Likely the preference towards suturing lies in the novelty of the stapling device. Many operators reported difficulty in actuating the stapler and none had used the device before. The cadaveric model texture may also have limited generalizability. Sample size is likely insufficient to adequately evaluate for operator safety as there were no injuries in either group.

Introduction: Optimisation of Emergency Department (ED) Sepsis Management is critically important to improve patient outcomes. At St James's Hospital sepsis initiatives have included a blood culture technique online video introduced in 2006, and development of an ED Sepsis Toolkit embedded in ED induction program in 2011, with update in 2015. A review of 2316 sets of blood cultures taken in ED in 2015 identified a blood culture contamination rate 11%. An economic evaluation on projected savings with a reduction in blood culture contamination rates indicated that a reduction in contamination from 11% to 3% could result in projected savings for one year of 915,000 euro, taking 5,000 euro as the published cost of a false positive blood culture 1. Aim: To identify and overcome barriers to compliance with Sepsis Management protocols in an ED setting and reduce blood culture contamination rates. Methods: A Sepsis Pathway Project team was formed with multidisciplinary representation from ED and Clinical Microbiology. Evaluation of blood culture processes and sampling techniques was undertaken. The ED pathway for sepsis care was process mapped and an observational study of blood culture techniques was performed. Results: A lack of ready access to all the necessary equipment components for blood culture sampling was observed. There were common issues of lack of stock and equipment was stored in multiple locations. Additionally, procedural variances with recommended standard for blood culture sampling techniques were identified. Intervention: To address these barriers a Mobile Sepsis Trolley with relevant diagnostic equipment and empiric antibiotics was designed and evaluated. A standardised educational programme delivered by the ED team was coupled with interdisciplinary simulated training on Sepsis management. This includes education on recommended blood culture sampling technique. Findings: Process mapping to identify barriers to sepsis management works well to identify critical areas for improvement. Sepsis Trolleys are now deployed in all areas of the ED. Observational study of blood culture sampling technique has shown improved compliance with protocol. Blood culture contamination rates have reduced from 11% to 7.4% in the 6 months post intervention (Q3/4 2017). Provisional costing data for our institution showed an average additional cost for each patient episode with contaminated blood culture of €6541. The reduction in blood culture contamination rates achieved in the 6 months post intervention have resulted in potential cost saving of €457,870. Conclusion: Our Sepsis Project Pathway Team have successfully used process mapping to identify critical areas for improvement in ED sepsis management. Introduction of mobile sepsis trolleys coupled with multidisciplinary educational program has improved compliance with sepsis guidelines and culture sampling technique. Significant potential cost savings have been demonstrated. Ongoing quarterly audit and PDSA cycles aim to continue improvement in sepsis guideline compliance and reduction of blood culture contamination rates. Following this evaluation feasibility of extension into other areas of the hospital will be assessed.

Background: Recognising temporal patterns in patients’ access to healthcare can provide benefits both to the health service by having greater supply in times of demand and by providing evidence to influence social change. The bulk of current evidence on temporal patterns focuses on welfare check distribution in the US. The check arrives at the beginning of the month and has led to findings that individuals are more likely to access healthcare after receiving this income, dubbed the “check effect”. This has been attributed to greater use of alcohol and/or drug abuse after the receipt of income, but also implies there might be a temporal link between an individual receiving a pay check and their drinking habits. Furthermore, as alcohol has been linked to increased levels of aggression, a community may be at risk of increased crime (i.e. assaults) at certain points in the month, common for when individuals receive a monthly salary. Therefore, this literature review investigates temporal trends in monthly behaviour which could allow better allocation of healthcare resources.

Methods: A critical literature review was conducted to evaluate the current evidence using the major medical databases: Medline, EMBASE, PsycINFO, PROSPERO and CINAHL. This identified 11 studies that indicated violent or substance abuse related behaviour after individuals had received income. A further 2 were identified after being repeatedly referenced in the original 11. This left a total of 13 studies included in this review.

Results: Two studies found no link between one-off payments to substance-dependent subjects for their participation and consequent substance abuse. However, eight studies that investigated temporal patterns of welfare check distribution on access to healthcare services found a “check effect”, which were associated with various patterns of substance abuse. Furthermore, two studies investigating mortality patterns across a month found a trend of increased mortality (including substance related mortality) in the first week of the month compared to the last week. This was suggested to be due to increased disposal income. The final study, investigated homicides and their relation to pay day. This did not find a definitive link between the rate of homicides and when people are paid.

Discussion: Repeating trends are important to recognise so that adequate healthcare provision can be provided. Within the literature, it seems that repetitive bulk deposits of income seem to increase access to healthcare. Within welfare check receiving individuals an important intervention may be staggering payments or appointing a trusted payee. However, this would not solve similar temporal trends observed within wider society, which could be due to receiving a monthly pay check. Therefore, further research will be required to investigate whether these trends may still exist due to monthly pay days, leading to potential implications within our society.

Background: Hypertension is an important public health worldwide challenge due to its high prevalence and strong association with cardiovascular disease and overall mortality. About 50% of all heart attack cases and about 60% cerebrovascular accidents are the consequence of higher blood pressure. The aim of this study was to evaluate a demographic characteristics, frequency, clinical presentation, comorbidities, therapeutic procedures and outcomes of patients with primary diagnosis of hypertension admitted to Emergency Department at Clinical hospital "Sveti Duh" between one year (1st April 2015 and 31st March 2016).

Methods: A cross-sectional, retrospective study for the period of one year was conducted. Data considered were all hypertension-related ED visits to the Clinical hospital Sveti Duh, Croatian teaching hospital, between 1st April 2016 and 31st March 2017. Diagnosis codes for hypertension included the International Classification of Diseases, codes (I10 -I15).The study was approved by institutional Ethics Committee.

Results. A total of 1346 hypertension-related emergency department visits occurred during the one-year study period (2,6% of all adult ED visits) with almost similar sex distribution (females 51,1% and males 48,9%). Mean systolic and diastolic blood pressures at presenting (triage) were 160.90 ± 15.90 (range 140-250) and 99.90 ± 6.20 (range 90-120), respectively. The most common accompanying symptoms were headache (73,3%), vertigo (66,5%) chest pain (51%), photophobia (49,6 %) and shortness of breath (49.2%). Major comorbidities include diabetes mellitus (44%) and coronary artery disease (35,8 %). Most patients who present with hypertension have previously been diagnosed as hypertensive, and were treated with antihypertensive therapy (95,9 %). Dietary sodium restriction was strongly advocated as a lifestyle behavioral change in 64 % patients, but only 11,6% patients were instructed to measure blood pressure at home and record the results in diary. Only 2 % of patients require hospital admission.

Conclusion: Among patients presenting to the ED with a chief complaint of hypertension or high blood pressure only 2% of patients require hospital admission. This number may indicates appropriate care of patients but also opens the questions of (non) justified their visit to the emergency department.

Background:

Acute infections and sepsis, as leading causes of morbidity and mortality, represent a major burden to healthcare systems. In the United States, an estimated 15 million patients are assessed each year for acute infections and sepsis in emergency departments (EDs). Diagnostic procedures to evaluate patients with suspected acute infections or sepsis in the ED are inaccurate or slow. Analysis of host-response signatures using RNA expression has been described for both diagnosis and risk stratification of patients with acute infections or sepsis. We here describe the development of HostDx™ Sepsis, a 30-host-gene PCR test that identifies i) the presence of an infection, ii) the type of infection (viral or bacterial), and iii) the severity of the infection using whole blood collected in PAXgene® RNA tubes. The HostDx Sepsis test is being developed as a cartridge-based, sample-to-answer, quantitative assay with turn-around time of less than 60 minutes.   

Methods:

To identify gene signatures specific for the presence, type and severity of infection, we analyzed publicly available microarray and NGS gene expression data sets from cohorts of children and adults with community- and hospital-acquired infection and sepsis. We discovered gene sets that can distinguish between infections and non-infectious inflammation, between viral and bacterial infections, and that can predict the severity of infection. Gene signatures were validated in 38 independent cohorts (total N=2,452) to establish clinical performance.

Results:

Validation performance for the presence of any bacterial infection in a hospital population showed a 94% sensitivity and 60% specificity (99% negative predictive value at 15% prevalence). The mean area under the receiver operator characteristics curve (AUROC) was 0.88 for prediction of 30-day mortality, markedly improving AUROCs for laboratory parameters and/or clinical scores including lactate and SOFA. To demonstrate proof of feasibility, a 7-gene subset signature distinguishing between viral and bacterial infections was successfully converted to a rapid multiplex PCR assay format, with correlation of 0.95 to a NanoString® standard based on digital detection and quantification of unique transcripts.

Discussion & Conclusions

Emergency physicians currently rely on a battery of tests with low accuracy to diagnose acute infections and sepsis. The host-response signatures described has demonstrated high diagnostic and prognostic accuracy in numerous independent cohorts. As a rapid triage assay HostDx Sepsis could allow for improved decision making for antibiotics, downstream testing, and level-of-care decisions.

Background

In emergency department (ED) chest pain patients, the European Society of Cardiology recommends the use of a 0h/1h high-sensitivity cardiac Troponin (hs-cTn) protocol. However, the recommendation is based on observational studies and the effects of the protocol when implemented in routine care is unknown. The aim of this study is to determine the safety and effectiveness of the ESC 0h/1h hs-cTnT protocol, supplemented with clinical assessment and ECG, when implemented in routine care

Methods

In this before-and-after implementation study with concurrent controls, all patients ≥18 years with a chief complaint of non-traumatic chest pain and possible acute coronary syndrome (ACS) will be included at the EDs of Skåne University Hospital at Lund and Malmö, Helsingborg Hospital, Ystad Hospital and Kristianstad Hospital in southern Sweden. Patients with STEMI, patients leaving against medical advice and non-Swedish residents will be excluded. The 0h/1h protocol identifies low-risk patients suitable for early discharge home, high-risk patients suitable for immediate hospital admission, and intermediate risk patients suitable for further diagnostic assessment. The protocol will be implemented at the Lund, Helsingborg and Ystad EDs but not at the Malmö and Kristianstad EDs which will be concurrent controls. Patient outcomes will be compared in the 10-month periods before and after the implementation (starting February 1, 2018) both at the protocol-implementing and control hospitals. The primary outcomes are the 30-day rate of acute myocardial infarction/all-cause death and the ED length of stay (LOS) in patients discharged from the ED. Secondary outcomes include the proportion of patients discharged from the ED and of non-ACS-patients admitted to the cardiac care unit, further cardiac testing within 30 days and health care costs.

Results

No results are available at this time (April 23, 2018). The main results of the study will be presented in 2019.  

Conclusion

If a 0h/1h protocol implemented in routine care can rapidly identify a large proportion of chest pain patients suitable for early discharge with no need for further cardiac testing, this may reduce ED and hospital crowding, objective testing, health care costs and will benefit both patients and the health care system.

There is increasing pressure on undergraduate medical students to get involved with research at early stages of their careers in order to secure the most

competitive training posts. Despite this, an opportunity for undergraduate research varies between medical schools and often there is no consistent way

in which research is incorporated into their curriculum.

To encourage medical students into emergency medicine and research, an emergency medicine research student selected component (SSC) was

developed in conjunction with Glasgow medical school. Successful students gained teaching and mentoring in the emergency department at the Royal

Alexandra hospital in Paisley, Scotland.

Students were given a research project, and were offered individual support with the aim of giving them early research opportunities and the possibility of presenting and publishing their work at international conferences.

The purpose of this study was to examine the impact of the SSC on students’ attitudes towards research and a career in emergency medicine. An online

questionnaire assessed the student’s level of interest, confidence and SSC research experiences.

Results indicated that the all students found the SSC to be influential or highly influential towards their level of interest in research compared to before

completing the SSC. All students said the SSC supervisor was academically stimulating, impressive as role model and supportive. 100% of students

agreed that the SSC had an influential contribution towards their level of interest in a career in emergency medicine. All students agreed that it would

increase their competitiveness for job applications. All of the students (16) had projects accepted for multiple international conferences

including Medicine24, The European society of emergency medicine in Athens, Greece, and to the annual scientific conference for the Royal College

of emergency of medicine in Liverpool. In conclusion, emergency medicine research SSC’s may be a novel approach to encouraging medical students into emergency medicine and research.

Background: Dengue fever (DF) causes a higher mortality in geriatric patients (≥ 65 years) than in the younger patients. Because there is still no adequate method to predict mortality in the geriatric DF patients, we intended to develop a novel nomogram to clarify this issue.

Methods: We recruited 627 geriatric DF patients who visited the study hospital between September 1, 2015, and December 31, 2015 for this retrospective case-control study. Variables including demographic data, symptoms, signs, vital signs, comorbidities, laboratory data, and 30-day mortality were analyzed. Univariate analysis and multivariate logistic regression analysis were used to recognize independent mortality predictors, which were further combined to develop a nomogram for predicting death in this population.

Results: The total mortality was 4.3% (27 patients died). The nomogram consisted three independent mortality predictors: bedridden (adjusted odds ratio [AOR]: 8.90; 95% confidence interval [CI]:0.93-64.36), severe hepatitis (AST>1000 U/L; AOR: 53.19; 95% CI: 5.79-691.21), and renal impairment (serum creatinine > 2 mg/dL; AOR: 7.20; 95% CI: 1.42-37.63).

Discussion & Conclusions: We developed a novel nomogram with user-friendly graphical interfaces which could generates the estimate to help predict mortality in geriatric DF patients. Further studies are warranted to validate its use.

Background: Residency is challenging time and improving wellness/resilience is paramount.  Interactions between like groups can be therapeutic.  In New Jersey, the “residency hierarchy” have developed a combine statewide annual residency assembly specifically for resiudents.  Objective: To determine residents sentiment regarding a statewide EM symposium.  Methods: A retrospective analysis and depiction of an educational series.  Three years of data were analyzed.  The planning committee met annually, with continued e-mail based communications.  Core lecturers were obtained locally, with grand rounds recruited nationally.  Resident participation incorporated: web based interactive CPC case, SIM lab competitions, or rapid lecture series.  “A priori” elected judges determine winners who received gift cards.  Receipt of the resident evaluation accompanied an allotted raffle ticket.  Evaluations were on a closed end questionnaire ranging 1-5 (1-poor, 2-below average, 3-Average, 4-above average, and 5-outstanding). Surveys analyzed: lecturer, location, food quality, networking opportunities, and exhibitors.  Conference funding was obtained by sale of tables, to various organizations.  Purchasers were allotted designated time/space with the residents.   Results: Resident participants totaled 439 with 54% (N=235) completing evaluations.  Combined overall topic scores: lecturer 4.5, exhibitors 4.3, location 4.2, networking 4.0, and food quality 3.8.  In 2015 the mean evaluation scores was 4.1, with lecturers receiving 4.5 the highest.  Individual topic scores ranged from for exhibitors 4.4 (95% CI 4.2-4.5), location 4.3 (95% CI 4.2-4.5), networking opportunities 4.1(95% CI 3.9-4.2), and food quality 3.7 (95% CI 3.4-3.9).  In 2016 mean overall score was 3.9 with lecturers receiving 4.6.  Individual topics ranged from exhibitors 4.2 (95% CI 4.1-4.4), location 4.1(95% CI 3.9-4.2), networking opportunities 4.0 (95% CI 3.8-4.2), and food quality 3.7 (95% CI 3.5-3.9).  In 2017 the mean score was 4.1 with lecturers receiving 4.3.  Individual topic scores in 2017 ranged from exhibitors 4.2 (95% CI 4.0-4.4), location 4.1(95% CI 3.8-4.2), networking 3.9 (95% CI 3.7-4.1), and food quality 3.8 (95% CI 3.6-3.9). Conclusion:  A statewide EM resident symposium is feasible and rated above average to excellent in most studied areas.

A PHYSICIAN-COORDINATOR REDUCES DOOR-TO-BALLOON TIME FOR STEMI PATIENTS IN EMERGENCY DEPARTMENT

T. Slutsky, MD, V. Zeldetz, MD,Y. Aizenberg, MD , H. Al Krinawi, MD,

E. Shnaider, MD, A.Kaplan, D. Shwarzfuchs, MD

Emergency medicine department, Soroka medical center, Beer Sheva Israel

Objectives

Acute ST elevation myocardial infarction (STEMI) is a life-threatening emergency condition. A patient whose STEMI is missed on evaluation has a ~25% likelihood of a very poor outcome, therefore immediate diagnosis and treatment of MI is one of the most important challenges of emergency medicine. Current guidelines for the treatment of STEMI recommend a door-to-balloon time (D2B) of 90 minutes or less for patients undergoing primary percutaneous coronary intervention (PCI).

Crowding in emergency departments is a worldwide problem.  Studies have shown a significant association between the emergency room crowding and STEMI patient's adverse outcomes. The emergency department (ED) in Soroka University Medical Center is the busiest in Israel (230,000 visits annually, of which 54,000 are in the internal medicine ED). Between May 2015 - April 2016 a novel "physician coordinator" work model was implemented in the internal medicine ED, in which a senior physician performs a medical triage (in parallel to the nursing triage), identifies emergency cases, especially STEMI, performs urgent procedures, allocates patients to physicians, and activates a cardiologist for immediate transfer of the STEMI patient to catheterization laboratory.

Methods

We compared the data from a period prior to implementation of the new work model (May 2014 - April 2015, "Period A") to a parallel period following implementation (May 2016 - April 2017, "Period B"), for patients with STEMI diagnosis.

We compared the door-to-balloon time (D2B) (in minutes) and the Timeliness rate (%) = the percentage of STEMI cases undergoing PCI in less than 90 minutes

Results

In Periods A and B there were 151 and 146 STEMI cases, respectively, diagnosed in the internal medicine ED. In order to produce comparison groups, we chose the cases occurring during regular ED staff hours (Period A – 50 cases, and Period B – 49 cases). Median D2B decreased from 97 minutes to 82 minutes (p = 0.033) and timeliness rate increased from 46% to 75.5% (p = 0.005), respectively.

Conclusions

Implementing a "physician coordinator" work model in the internal medicine ED led to significant improvement in treatment measures: reduced D2B time and increased timeliness rate, for STEMI patients.

Background

The emergency department (ED) is a rich, problem-based, learning environment. ED handover can present teaching opportunities to maximise clinical teaching.

Methods

The aim of this study is to describe the educational content delivered at ED handover at an Irish inner city university hospital. A dedicated scribe documented learning points from the daily 4pm ED handover on a whiteboard. The dataset from each ED handover was coded using NVivo software. The dataset was analysed by doing a word cloud and thematic analysis.

Results

Data was captured from twenty-three ED handovers. The two most prominent highlighted words were ‘patient’ and ‘treatment’ on the word cloud analysis. Fifty-six codes mapped to fourteen basic themes, encapsulating twelve medical specialties, clinician welfare and clinical examination.  A hierarchy tree visualized the emphasis of ED handover teaching on the themes of medicine, cardiology, trauma and toxicology.

Discussion

This is the first qualitative study analyzing education delivered at ED handover. Our study confirms the utility of ED handover as an important learning opportunity.

Conclusion

Education delivered at emergency department handover can enhance learning opportunities for ED clinicians.

Introduction and Background: Case reports and Case studies are the main way of reporting from major incidents, mass casualty incidents and disasters. Prospective studying is notoriously difficult in this setting. Published reports in accessible journals are mostly non-homogenous making comparison difficult. There are several guidelines and templates available, which are rarely being used in readily accessible published studies. We wanted to study the process of reporting to identify difficulties and obstacles, while also getting first hand ideas and improvements from the reporters. This to better understand the process of writing reports for the means of improving future reporting. There are few studies on this field. One study on the experiences of using template reporting - but none, to our knowledge which study the whole process of reporting.

Methods: A qualitative study design was chosen, in the form of semi-structured interviews. Participants were selected from a comprehensive literature search, based on case-studies or case-reports of a major incidents, mass casualty incidents or disasters, which were published during the last 5 years. The timeframe was set so the participants would be more likely to have a memory of the process of reporting. For this study, only participants from Europe were selected. Participants were contacted in a random order, and the researchers themselves conducted the interviews. Ethical approval given by Committee of Medical Ethics at VUB (Vrije Universiteit Brussel). Study registered at Commission for the Protection of Privacy (CCP) in Belgium.

Results: The interview was themed around initiative, initiation, founding, data collection, and the use of guidelines and/or templates. We were able to identify specific obstacles that are of major importance for improving research on this field. Data collection proved to be one of the more challenging parts of the reporting-process. Guidelines and templates were often chosen based on how easily accessible and user-friendly they were. Along with presenting specific and personal experiences from the reporters/participants, we also highlight the importance to gather this kind of first hand experiences to improve systematic reporting in emergency and disaster medicine.

Conclusion and Relevance: This study presents fist-hand experiences from reporters of major incidents, mass casualty incidents and disasters. Aspects that are highly valuable in further research, and possible improvements in the process of documenting and sharing reports on major incidents, mass causality incidents and disasters, are presented here. Suggestions of improvements on how hospitals and governmental institutions can promote and help reporters in the process of making these reports is of utmost importance for an advancement in emergency and disaster medicine.

Background 

Acute bronchiolitis (AB) represents one of the most frustrating care conundrums in pediatrics. The mainstay of treatment for this illness is supportive care, as no therapy has proven particularly useful. Although evidence-based guidelines recommend primarily supportive care, many unnecessary treatments persist, contributing to a quality problem of overtreatment. However, standardizing treatment requires multifaceted approach, which is still a challenge.

Objective

To implement and assess a quality improvement (QI) initiative to reduce the overuse of unnecessary treatments in infants with AB in Primary Care (PC) settings and the referral Pediatric Emergency Department (ED).

Methods

We designed and executed this QI during two bronchiolitis seasons [October-Mars of 2016-2017 (pre-intervention period) and 2017-2018 (post-intervention period)].

Between those seasons we distributed an evidence-based management protocol, informative posters and badges for uniforms with the slogan "Bronchiolitis, less is more". Furthermore, we developed interactive sessions with on-line data collection and feed-back. The interactive sessions mainly consisted in the review of the existing evidence on the treatment of AB and the discussion about the existing barriers to apply what is known about this disease. Pediatricians received a weekly report with personal and global data on the prescription of bronchodilators.

The main outcome was the rate of infants receiving salbutamol. Secondary outcomes were the rate of infants receiving epinephrine, antibiotics and corticosteroids.

The control measures were the rate of ED visits and hospitalization due to AB in infants from the two PC areas included in the study, triage level, length of stay (LOS) in the ED, Pediatric Intensive Care Unit (PICU) admission and unscheduled returns with admission within 72 hours.

The data were collected from the computerized medical record. The study was approved by the local Ethics Committee and won the annual research grant from the Spanish Society of Pediatric Emergency Medicine in 2018. No other external funding was secured for this study.

Results

During the study period we reviewed 1876 episodes in the ED (1021 in the pre-intervention period and 855 in the post-intervention period) and 1129 in PC settings (658 and 471, respectively).

In the ED, salbutamol was reduced from 13.8% (95% CI, 11.8-16) to 9.1% (95% CI, 7.3-11.2) (p<0.01) and epinephrine from 10.4% (95% CI, 8.6-12.4) to 9% (95% CI, 7.2-11.1) (not significant [n.s.]). The use of antibiotics did not vary significantly [2.4% (95% CI; 1.6- 3.5) to 3.1% (95% CI; 2.1- 4.5)]. The use of corticosteroids was anecdotal in the ED, less than 1%.

In PC setting salbutamol was reduced from 38.3% (95% CI, 34.6-42.0) to 15.9% (95% CI, 12.9-19.5) (p<0.01), corticosteroids from 12.9% (95% CI, 10.5-15.7) to 3.6% (95% CI, 2.2-5.7) (p <0.01), and antibiotics from 29.6% (95% CI; 26.2 - 33.2) to 9.5% (95% CI; 7.2- 12.5) (p <0.01). The use of epinephrine was anecdotal in PC setting.

No significant variations were noted related to control measures.

Conclusions

Using a QI initiative, we safely decreased the use of unnecessary treatments in infants with AB. Collaboration between PC units and ED appears as an important context factor for successful improvement.

Introduction

A crucial component of a hospital’s disaster plan is an efficient staff recall communication method to ensure adequate staffing in the face of a sudden influx of patients. Many hospitals and healthcare services use a “calling tree” protocol to contact staff members and recall them to work. Alternative staff recall methods have been proposed and explored in various drills and real-life situations.

Methods

An unannounced multidisciplinary randomized emergency department (ED) staff recall drill was conducted at night - when there is the greatest need for back-up personnel and staff is most difficult to reach. The drill was performed on December 14, 2017 at 4AM and involved ED staff members from 3 hospitals which are all part of the McGill University Health Centre. Three different tools were compared: manual phone tree, WhatsApp Group, and custom-made hospital Short Message Service (SMS) system. The key outcome measures were proportion of responses at 45 minutes and median response time for each of the three methods.

Results

One hundred thirty-two participants were recruited. There were 44 participants in each group after randomization. In the manual phone tree group, 18 (41%) responded within 45 minutes. In the WhatsApp group, 11 participants (25%) responded in the first 45 minutes. In the SMS group, 7 participants responded in the first 45 min (16%). Manual phone tree was significantly better than SMS with an effect size of 25% (95% confidence interval for effect: 4.6% to 45%; p=0.018). Conversely, there was no significant difference between manual phone tree and WhatsApp with an effect size of 16% (95% confidence interval for effect: -5.7% to 38%; p=0.17) There was a statistically significant difference in the median response time between the 3 groups with the phone group presenting the lowest median response time (8.5 minutes; range: 2 to 8.5 minutes) (p = 0.000006).

Conclusion

Both the phone tree and WhatsApp groups had a significantly higher response rate than the SMS group. There was no significant difference between the proportion of responses at 45 minutes in the manual phone tree and the WhatsApp arms. This study suggests that WhatsApp may be a viable alternative to the traditional phone tree model.  Limitations of the study include volunteer bias and the fact that there was only one communication drill which did not allow staff members randomized to the WhatsApp and SMS groups to fully get familiar with the new staff recall methods.

Introduction

Coagulopathy resulting from bleeding and hypovolaemic shock in trauma patients has been well-described. Current management involves balanced transfusion of blood products during resuscitation and targeted therapy for specific coagulation abnormalities revealed by thromboelastography.

A similar coagulopathy has been described in adult patients with isolated traumatic brain injury (iTBI) without shock, although the identification and management of coagulation abnormalities in this group is not yet standard care. The aim of this study was to identify the proportion of patients with iTBI presenting to a regional paediatric major trauma centre who had standard laboratory coagulation studies performed within the first 24 hrs and to report the detection rate (prevalence?) of coagulopathy identified and any associations with poorer outcome.

Method

A retrospective search of the Trauma Audit and Research Network (TARN) database of a paediatric major trauma centre serving the southwest of England was performed to identify patients presenting with iTBI (abbreviated injury score head region >3 all other regions <3) between 01 January 2016 and 31 December 2017. Demographic, mechanism of injury, outcome and hospital resource utilisation data were recorded. The computerised laboratory results system was then interrogated to obtain the results of any standard coagulation tests performed. The presence of coagulopathy was defined as a APTT < 23.0 or >32.0 and INR >1.2. Cases were categorised according to the presence or absence of coagulopathy. Comparisons between these group was performed using SPSS version 24. Categorical data were considered using chi-squared analysis and continuous data with Mann-Whitney U test or student’s T-test as appropriate.

Results

105 cases of paediatric iTBI were identified in whom the mortality was 0%. 43 cases (41%) underwent laboratory coagulation testing with coagulopathy identifiable in 15 (14%).Compared with non-coagulopathic patients, paediatric iTBI patients with coagulopathy had a lower presenting GCS (46.2% moderate or severe, p<0.035), were more likely to undergo intubation in ED (85.7% % vs 13.6%, p=0.027), and to have a greater mean length of total hospital stay (5.65 vs 2.36 days, p<0.05). A non-significant association with higher energy mechanism of injury was detected (41.9% vs 63.6%, p=0.26). In hospital mortality, ITU length of stay and Glasgow outcome scores did not vary significantly between the groups.

Conclusion

Coagulopathy is common in paediatric patients with iTBI and is associated with a more severe injury and greater length of hospital stay. Screening for coagulopathy may be under-used at present. The mortality rate in this study was surprisingly small and hence no associations with adverse outcome were demonstrated. Larger studies exploring coagulopathy in children with iTBI would be justified. Targeted correction of coagulopathy in iTBI could potentially be a novel therapeutic avenue.

INTRODUCTION: Frequent attenders make up a significant number of all attendances to UK Emergency Departments (ED) each year, with many UK trusts developing policies and systems for improving patient outcomes for this cohort, reducing ED workload and making financial savings. There is limited research characterising this group in the UK paediatric population. The Royal College of Emergency Medicine's guideline on managing frequent attenders encourages identification and support of this patient cohort, but makes no specific reference to young people or children. The aim of this project was to gather epidemiological information on the paediatric frequent attenders at an urban tertiary paediatric hospital, in order to identify trends within this group that could be targeted for intervention.

METHODS: We retrospectively analysed data for all patients (<16 years old) who presented on ten or more occasions to the Bristol Royal Hospital for Children ED during the period August 2015 to July 2016. We used scanned electronic records to collect information on clinical presentation and demographic data for each attendance.

RESULTS: In total 47 patients were identified as attending ten or more times within the 12-month study period, accounting for a total of 584 attendances. The median number of patient attendances was 11 (range 10 to 27). Median age at presentation was 26 months. Approximately half of presentations (n=286, 49%) occurred out-of-hours (17:00 to 07:59). Patients were admitted to the observation unit, or to an in-patient bed on 42.8% (n=250) occasions. The ethnic group was recorded as white-British for 79% (n=37). Common reasons for attendance included respiratory difficulty (n=101, 17.3%), fever (n=87, 14.9%), feeding tube problems (n=72, 12.3%), musculoskeletal issues (n=35, 6.0%), seizures (n=27, 4.6%), and overdose (n=22, 3.8%). Of the 47 patients analysed, 36 had complex pre-existing medical conditions including seven oncology patients, eight patients who were born prematurely, and four patients with a confirmed neurological diagnosis.

DISCUSSION: The data gathered from this 12-month period reveals that the majority of paediatric frequent attenders in our sample were younger than 3 years old, with far fewer adolescent patients than initially expected. It is also clear that most of the patients in our cohort had complex medical backgrounds or pre-existing conditions that were responsible for their ED attendances. The high admission rate compared to our overall paediatric ED population represents the higher morbidity carried by this group. While presentation with some medical complaints is unavoidable, we postulate that increased patient and parent education could minimise some reattendances, particularly in those presenting with minor illness. Further allocation of resources towards areas identified as causing reattendance (e.g. feeding tube problems) or support for 'high-risk' patient groups (ex-premature or oncology patients) could also decrease frequency of attendances.

CONCLUSION: We hope that by identifying trends within paediatric frequent attender data we can target interventions to enhance patient and carer experience and avoid ED presentations that could be better managed elsewhere. Further research is required on this subject.

Background:

The NICE Major Trauma Guidelines were introduced in February 2016 and advocate the administration of 1g tranexamic acid (TXA) in patients with major trauma and active or suspected active bleeding. Whilst not directly recommended, papers elsewhere suggest that this initial bolus is followed up by an 8-hour infusion of tranexamic acid, generally out with the prehospital/emergency department (ED) setting.

Aims:

To establish if 1g TXA was administered in the early stages of patient injury and, if appropriate, a 2^nd dose was administered as an infusion during admission. Secondary aims included a literature review of evidence supporting TXA use in trauma and if a mortality benefit was observed in this cohort.

Method:

Following literature review of supporting evidence, a retrospective cohort study was designed. Study population included patients in the Emergency Medical Retrieval Service (EMRS) database over a 6-year period who were subsequently transported to the Royal Alexandra Hospital (RAH) or Inverclyde Royal Hospital (IRH). All patient records with the prespecified definition of ‘major trauma’ were included. Predefined data concerning demographics, TXA administration and mortality was collected using clinical portal and physical records. Patients were excluded if they were under 16 years old, were secondary transfers or if they were dead at scene.

Results:

112 patients were included of which 11 were administered the 1^st dose of TXA, 9 within 3 hours of injury. Of these, 7 received the dose pre-hospital and 2 in the ED. Only one patient received a 2^nd 1g bolus at ward level, given 8 hours after the initial dose.

Two patients in the cohort died within the first 24 hours, one receiving TXA 72 minutes after initial injury. No other patients died in the 30-day period after injury regardless of TXA dosing.

Discussion:

Despite trial data heavily supporting the use of TXA in reducing mortality in major trauma with suspected bleeding, it is clear that this evidence has not yet been translated into practice identified in our patient cohort.

Although no significant reduction in mortality was observed in those who received TXA this study is limited by a low number of patients receiving the initial and secondary TXA boluses. This low population likely being due to neither the RAH or IRH being designated major trauma centres and that the mechanism of injury defined as ‘major trauma’ clinically does not require administration of TXA.

With current evidence supporting the administration of a secondary TXA dose further efforts should be made to encourage this through education of both pre-hospital and hospital practitioners. Although not within the scope of this study, assessing for the scale of morbidity between groups may provide further evidence for administration of secondary TXA dosing both in and out of hospital.

Background :

Acute back pain commonly presents to the Emergency department (ED). Although 98% of cases have no significant cause it is important to identify those with serious pathology with an accurate history and examination. Missed back pathology has significant implications for patient outcomes and carries a high risk of litigation therefore clear documentation is important. We wanted to review our documentation and develop a proforma to improve areas identified for improvement.

Methods:

We retrospectively reviewed notes for all presentations to the ED with back pain from July 1^st 2017 to 31^st August 2017 and excluded all cases where other pathology was noted. Demographic data and documentation of history; red flags; examination findings and discharge advice were noted.

Results:

A total of 142 patients were identified: 69 male; 73 female, median age 41.5yrs; range 17-89yrs.

93 patients presented with atraumatic back pain and 49 related to trauma.

141 patients had clear documentation of symptoms but only 118 had presence or absence of red flag symptoms documented. 55 patients had a note of observation findings; 47 had range of movement documented; 47 had straight leg raise findings noted and only 1 commented on femoral stretch test. 83 documented tone; 111 power; 109 sensation and reflexes. 60 had documentation of perianal sensation and 26 had a PR performed as there was concern regarding cauda equina syndrome. 17 had a post void volume. Of patients over 65 yrs only 28 of 41 had abdominal examination documented.  Only 89 patients had clear discharge advice documented.

The initial findings noted many areas for improvement and subsequently a new acute back pain proforma has been introduced. This has clear guidance for symptoms and specifically highlights key questions for red flag symptoms. The examination includes sensory and myotomes clearly and highlights the need for documentation of PR and post void residual volumes where cauda equine syndrome is suspected. Documentation of abdominal examination for >65yrs is also higlighted.

We have recently introduced this proforma and have used this 16 times so far. We hope to have additional data for the conference available. For these cases, there is clear documentation in all cases for symptoms including red flag symptoms; power; sensation and reflexes. 15 patients had inspection and range of motion documented, 12 had straight leg raise and 4 femoral stretch test documented. In all cases where cauda equina syndrome was considered perianal sensation, PR and post void residual volumes are documented. In >65 yrs 1 patient had abdominal examination noted and 1 did not. 9 cases had clear documentation of discharge advice.

 Discussion and conclusion:

The initial audit showed we were poor at documenting significant red flag symptoms and clearly documenting important examination findings. The subsequent introduction of the proforma, although early days, has already shown an improvement in the standard of documentation. It has also acted as an aide memoire as it specifically highlights key questions in a tick box format and provides guidance on need for investigations and senior review.

Background

In our DGH, we have on-site maternity services. Booked patients over 13 weeks gestation can self refer to maternity triage via telephone contact. Despite this a number of patients self present to the Emergency Department with a variety of complaints. There is a protocol in place for those who present with bleeding in the first trimester. We wanted to review the characteristics of patients who self present in terms of complaints, initial management and outcome to ensure our practice is consistent, safe and prevents unnecessary ED review of patients.

Method

ED notes were retrospectively reviewed over a 2 month period from 01/07/2017 to 31/08/2017, for any patient who presented with self reported pregnancy at triage or a positive urinary HCG.

Demographic data; date and time of attendance; gestation if known; urinary HCG result and outcome were noted. In addition, all patients were retrospectively scores using the MEOWS observation chart with amended normal values for pregnancy. Compliance with the bleeding in early pregnancy protocol (EPC) was noted if applicable.

Results

A total of 68 pregnant patients attended the ED in the period studied, with total presentations to the ED of 11, 061 (0.06%). Of these 48 (71%) presented outwith Mon-Fri 9am-5pm. 42 patients were under 12 weeks gestation so did not have the option to self refer.

29 of 42 patients were potentially suitable for referral to EPC. However, only 11 of these (38%) were appropriately referred from triage. Of those deemed unsuitable for direct referral, 6 had an analgesia requirement, 2 were haemodynamically unstable, 3 were asymptomatic (1 pregnancy diagnosed at triage), 1 attended with an injury requiring ED review and 1 was referred to ED medical staff due to nursing concerns re social circumstances.

The 26 patients presenting at greater than 12 weeks gestation had a wide range of presenting complaints. 12 were referred directly to O&G from triage, 14 seen by ED staff of whom 9 were referred on to O&G for review. It is not known how many were subsequently discharged from O&G immediately following assessment.

When observations were charted using the MEOWS score, 33 patients scored at least 1, compared with 13 using a standard adult EWS. Of note 2 patients >30 weeks gestation did not have observations performed.

Discussion

A number of areas to improve quality of care were highlighted.

Our EPC protocol is not consistently followed resulting in increased workload for inpatient teams. Many staff find the highly emotive issue of potential loss of pregnancy is difficult to address in the pressured triage area. A leaflet explaining about outcomes of bleeding and inevitability of miscarriage if that is the cause may help address this.

Introduction of MEOWS and observations in all pregnant patients will reduce the potential to miss serious diagnoses such as pre-eclampsia.

Pregnant patients form a very small proportion of the ED workload. Lack of familiarity with pregnancy-specific problems means staff lack confidence in decision making which could be alleviated by the development of guidelines in conjunction with our specialist colleagues.

Background :

Musculoskeletal back pain is a common presentation to the Emergency Department (ED) and is a leading cause of morbidity in those under 70 in the UK.  We wanted to review the characteristics of patients attending with back pain to determine the workload of this presentation on the ED and subsequent investigations and need for admission in these patients.

Method :

We undertook a retrospective note review of all patients who had initial presenting complaint of back pain from 1^st July 2017 to 31^st August 2017. We recorded demographics; diagnosis and subsequent management.

Results:

221 patients presented with acute back pain. 79 patients were excluded as they had an alternate diagnosis. This included 21 patients with chest pathology; 15 with renal pathology; 10 with abdominal pathology; 8 with pain from their neck; 5 from their shoulder; 3 from their hip; 3 related to a head injury; 11 redirected and 3 who left without being seen.

The remaining 142 patients had a diagnosis of musculoskeletal back pain. 69 were male, 73 female; median age 41.5yrs, range 17 to 89yrs.

93 patients had atraumatic back pain and 49 had sustained an injury. 95 patients self referred; 29 arrived by ambulance; of referrals from healthcare there were 9 from GP; 6 from NHS 24; 2 from minor injury unit and 1 from physiotherapy. 98 patients presented out of hours, 53 of these over the weekend. 

77 patients were discharged from the ED directly with no follow up; 23 were advised to see their GP; 5 were referred direct to physiotherapy and a total of 28 patients were admitted with 10 discharged to return for review and scan.

An urgent MRI was indicated in 21 patients, of which 9 were performed on the same day; 9 the next day; 1  48hrs later and 2 at 8 days. 3 cases of  cauda equina syndrome were identified requiring immediate neurosurgical review and surgery.

105 patients required prescribed discharge analgesia on discharge including co-codamol; oromorph; diazepam and a choice of NSAIDS. There was no consistency in medication prescribed. 89 patients had documented discharge advice.

Discussion and Conclusion:

The majority of patients with back pain will have a benign diagnosis, but all require detailed assessment to identify those with a more significant cause, resulting in significant workload in terms of admission and need for subsequent investigation with 15% of patients requiring an urgent MRI scan. The majority (64 %) occurs out of hours, when MRI scans are unavailable therefore if cauda equina is suspected a neurosurgical consultation is required.

Of those presenting with acute back pain, 36 % of patients had unrelated potentially significant causes, suggesting accurate triage is critical in these patients.

Discharge prescriptions and advice are inconsistent, and a patient information leaflet has been developed in conjunction with clear guidelines for management including analgesia. Adherence will be subsequently audited.

Background: 

Emergency Department (ED) capacity is an ongoing and well publicised issue. Pre-alerts are given by the ambulance service for potentially or actually unstable patients and as such require rapid availability of appropriate capacity and staff. We reviewed the number and time of arrival of pre-alerted patients with respect to our compliance with the 4-hour target on the day of presentation. 

Methods: 

We retrospectively audited all pre-alerted cases presenting to the ED within a United Kingdom (UK) district general hospital from 1st September 2016 to 31st August 2017. Details of attendance time and date; discharge destination and final diagnosis were noted from both pre-hospital and ED documentation, and hospital discharge letters. 

Results: 

A total of 2468 patients were pre-alerted representing 4% of the overall attendances in this time period (63,334 attendances). On 165 days we achieved compliance with the 4-hour target where on average 168.29 patients were seen (minimum 126, maximum 226, interquartile range 1 (IQR) 152, IQR3 183). We had 199 non-compliant days where an average of 178.72 patients were seen (minimum 122, maximum 236, IQR1 165, IQR3 190). 

Days where we achieved compliance with the 4-hour target had an average of 6.34 patients pre-alerted (minimum 1, maximum 15, IQR1 4, IQR3 8) compared with non-compliant days where an average of 7.15 patients were pre-alerted (minimum 2, maximum 17, IQR1 5, IQR3 8.5) 

563 patients were pre-alerted between 23:00 and 08:00 with 44% on compliant days (total 247 patients) and 56% on non-compliant days (total 316 patients). 

Where there was a need for critical care involvement, there was higher proportion on non-compliant days (60% (60 days)) compared with compliant days (40% (41 days)).

It was also noted that if > 1 patient was pre-alerted within an hour this affected our ability to comply with the 4-hour target. Where this occurred twice in a day we achieved compliance in 46% of cases (84 episodes) versus 54% non-compliance (98 episodes); three times per day we achieved compliance in 25% cases (7 episodes) versus 75% non-compliance (21 episodes) and four times we achieved compliance in 33 % cases (2 episodes) versus 67% non-compliance (4 episodes).

Discussion and Conclusion: 

This data shows that on days where we have more patients pre-alerted; who present overnight; present within an hour of each other; or require critical care involvement we can’t achieve compliance with the 4-hour target. This is likely to be due to a number of factors including workforce availability, seniority and workforce planning targeted at average attendance rather than surges. Issues around exit block and capacity within the department also affect compliance. This data emphasises the work Royal College of Emergency Medicine (RCEM) are currently doing around the UK to reinforce these issues at government level. 

Background: 

Emergency Department (ED) capacity is an ongoing and well publicised issue, with acuity of illness a major contributor to this. Pre-alerts are given by the ambulance service for potentially or actually unstable patients and as such require rapid availability of appropriate capacity and staff. We reviewed the different pathologies by systems (e.g. cardiology and neurology), when they presented and what level of care they required.

Methods: 

We retrospectively audited all pre-alerted cases presenting to the ED within a UK district general hospital from 1st September 2016 to 31st August 2017. Details of attendance time and date; discharge destination and final diagnosis were noted from both pre-hospital and ED documentation, and hospital discharge letters. 

Results: 

A total of 2468 patients were pre-alerted representing 4% of the overall attendances in this time period (63,334 attendances).

The most common system requiring pre-alerting was respiratory (678 patients; 27% of standbys) followed by neurology (580 patients; 24% of standbys), cardiology (351 patients; 14% of standbys), renal (159 patients; 6% of standbys), toxicology (124 patients; 5% of standbys) and orthopaedic (84 patients; 3% standbys).

Respiratory (110 patients; 16% total) and toxicology (27 patients; 22% total) pre-alerts were most likely to come in on a Sunday, neurology (93 patients; 16% total) and cardiology (57 patients; 16% total) on a Tuesday, renal (30 patients; 19% total) on Fridays and orthopaedics (17 patients; 20% total) on a Thursday.

In terms of final outcome, cardiology pre-alerts resulted in the most coronary care unit (CCU) admissions (107; 30.48% of cardiology standbys) and transfers out of hospital (14; 3.99% of cardiology standbys) which were most likely for primary percutaneous coronary intervention. Of the 251 pre-alerts that required high dependency unit (HDU) admissions respiratory was the most common (72; 10.62% of respiratory standbys) followed by neurology (54; 9.31% of neurology standbys). 118 pre-alerts resulted in intensive care unit (ICU) admissions which were predominantly for neurology (33; 5.69% of neurology standbys) and toxicology (23; 18.55% of toxicology standbys).

Pre-alerts requiring higher levels of care (HDU, ICU, CCU and straight to theatre) in relation to daytime (08:00-23:00) and night-time (23:00-08:00) show more demand during the day (379 cases) versus night (128 cases). However, the 128 night cases represents 22.74% of all pre-alerts within that timeframe whereas 379 equates to 19.90% of daytime standbys. We also note that cardiology pre-alerts are more likely to require higher level care (130 cases; 25% of all higher level care pre-alerts) followed by respiratory (104 cases; 20% of all higher level care pre-alerts).

Discussion and conclusion:

The data above shows there is a range of different standbys that present across the week with cardiology and respiratory pre-alerts making the bulk of our referrals to higher level care. When comparing night and day pre-alerts we can see proportionally the number requiring higher level care is increased at night time meaning an increased demand when the workforce tends to be at its lowest. This therefore supports the need for more senior cover over night and adjustment of current workforce organisation.

Introduction:

Minimizing out-of-hospital-time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome or acute strokes. Choosing the right means of transport is important. Our main objective was to compare out-of-hospital times by helicopter versus ground services when estimated time of arrival on scene was over 20 minutes.

Methods:

We propose a retrospective observational monocentric study following two cohorts. The Helicopter group (H) included patients with severe trauma, acute coronary syndrome or acute stroke transported by helicopter. The Ground group (G) consisted of patients with the same conditions but transported by ground services. We enrolled patients in the department of the Gard (South of France) with severe trauma, acute coronary syndrome or strokes from January 1st to December 31, 2014, with an estimated arrival time at scene of at least 20 minutes.  Patients refusing to participate, under 18 years old, under guardianship, or curatorship were not included. We did not include patients transported by ground services during the days and hours the helicopter could not fly.

Our main objective was to compare out-of-hospital times by helicopter versus ground transport when estimated time of arrival on scene was more than 20 minutes. We defined the primary endpoint as the out-of-hospital time, defined as the period between the distress call to the SAMU “15” hotline and arrival time at the ED or the receiving ward.

Our secondary outcomes were:

• To determine a cut-off distance from the hospital to the scene of the event where out-of-hospital helicopter times are shorter than ground transport

• To identify variables that predict sending helicopters

We described patient characteristics using sample size and percentages for qualitative variables and using mean and standard deviation, or median with interquartile depending on type of distribution, for quantitative variables. We compared qualitative variables in each groups by Fisher exact test and quantitative variables by Student test. We assessed the correlations between time of distress call and time of arrival at hospital using Locally-Weighted Scatterplot Smoothing (LOESS) regression.

 Results:

Two hundred and thirty-nine patients were included in the study; 118 were in the G group and 121 in the H group. Distances for the H group were higher (62.1 kms vs 27.6 kms; p<0.001). H group patients were more severe. They had a lower Glasgow scale (12.8 vs 14.5; p<0.001), required more frequent intubation (23 vs 4; p<0.001), surgical procedures (23 vs 10; p=0.037), and hospitalisation in intensive care units (ICU) (32 vs 6; p<0.001). When distances were over 35 kms the H group was faster. We identified distance, need for surgery or intensive care hospitalisation as three predicting factors for choosing helicopter over ground modes of transport.

 Conclusion:

In cases of severe trauma, acute coronary syndrome or acute stroke, emergency medical helicopter transport should be chosen over ground transport when patients are in a severe state and distance is further than 35 kms from the hospital.

Background:

Chest pain is a common and highly variable ED presentation and so it is vital to have an efficient and reliable tool to differentiate between patients who are likely to be presenting with ACS (‘high risk’) and those who are unlikely (‘low risk’). This study aims to determine whether the new ‘Suspected Acute Cardiac Chest Pain Protocol’ being used by the Royal Alexandra Hospital (RAH) Emergency Department (ED) is a safe, accurate tool for identifying chest pain patients at low risk of acute coronary syndrome (ACS).

The RAH ED uses the ‘Suspected Acute Cardiac Chest Pain Protocol’ to distinguish between chest pain patients. It uses a patient’s HEART score and troponin levels to set defined levels of risk. It is used in conjunction with clinical judgement. 

Patients identified as ‘low risk’ are discharged from ED and followed up with the Chest Pain Assessment Unit (CPAU) where their further management (like referral to Golden Jubilee National Hospital, GJNH) is decided by a senior cardiologist (this will be referred to as the ‘low risk chest pain (CP) pathway’).

Method:

Over a one-year period, 284 patients were referred from ED to CPAU via the low risk CP pathway and recorded on the hospital database. Relevant patient details were collected using the Trakcare and Portal systems and collated into an Excel document for evaluation. 

Results:

24 unfavourable events were identified. These include inappropriate clinical or clerical management within the low CP pathway and adverse events that occurred post-follow up. It’s important to note this excludes patients who are initially evaluated as ‘high risk’ using the protocol and then downgraded to ‘low risk’ based on clinical judgement.

5 cases were inappropriately referred onto the CPAU (1.2%): 2 due to inappropriate non-cardiac presenting complaints and 3 due to abnormal initial investigations. Only 1 of these resulted in a potentially dangerous missed diagnosis of ACS (0.24%). However due to the nature of the low risk CP pathway, this was identified and corrected during CPAU follow up. 2 patients faced a delayed follow up to CPAU and a delayed referral to GJNH (0.48%) due to clerical errors.

No adverse events following post-follow up where associated with inappropriate use of the low CP pathway. The mortality rate at 6 months was 0.72% due to 3 deaths: 2 were not cardiac related and 1 was due to an unknown cause. There was only 1 major cardiac event (STEMI) noted (0.24%) and it was not due to poor medical management as the correct preventative measures had been put in place. The other 13 adverse events were either non-cardiac problems or were benign readmissions unrelated poor ED or CPAU care. 

Conclusion:

This study suggests that the combination of an accelerated diagnostic pathway, like the ‘Suspected Acute Cardiac Chest Pain Protocol’, plus clinical judgement allows physicians to quickly and accurately identify those at low risk of ACS. In the future, continued careful clinical judgement and meticulous documentation will ensure patients are correctly identified as ‘low risk’ and receive timely, appropriate management.

Aims: As an objective assessment of chest pain presentations, high sensitivity troponin is measured, however due to the range of conditions which raise troponin and the sensitivity of modern assays the clinical picture remains important. Mistreating a raised troponin carries the risks associated with  acute coronary syndrome (ACS) treatment, such as haemorrhage. With this work we hope to identify if there has been any overtreatment of chest pain presentations and whether this had led to any adverse outcomes.

Methods: A patient cohort of all acutely measured troponins in the hospital within a six-week period were identified. Data was then collected from patients who had presented to A&E, either by self referral or ambulance and were admitted with suspected acute coronary syndrome. For each patient a range of data was collected including: first troponin level, ECG findings and presenting complaint. Each patient was followed through till discharge. Adverse outcomes, such as haemorrhage following ACS treatment were highlighted.

Results: 8% of presentations received dual antiplatelet therapy with an antithrombin when ACS did not follow as the final diagnosis. Two patients received a potentially high-risk combination of full ACS therapy with Apixaban. 

Conclusion: The potential risk of administering ACS treatment should continue as a point of education in the emergency department and care should be taken when treating anticoagulated patients. Additionally, continued awareness of non-ACS causes of elevated troponin remains crucial.

Background: Plain film radiographs (X-rays) are a key investigative tool used by clinicians in the Emergency department (ED). It is standard practice that every X-ray ordered by the clinicians working within the ED is reviewed and reported by radiologists; on occasion discrepancies occur between the interpretation by the clinician and the radiologist. Addenbrooke's Hospital employs a safety-net whereby consultants check abnormal radiological reports and corroborate this with the patient's medical notes during a designated Admin, Trauma and Teaching (ATT) shift. This aims to ensure that any radiological finding identified by the radiologist that was missed during the initial assessment by clinicians is acted upon.

Aims: To analyse missed radiological abnormalities as recorded in the Microsoft Access database in order to identify the trends and clinical significance of these abnormalities to help develop relevant educational materials for staff. Furthermore, this study aimed to evaluate the use of this element of the safety net system by consultants and recommend changes to facilitate the logging of the missed findings.

Methods: This study was a retrospective review of a Microsoft Access database used to log abnormalities missed on X-rays in the ED at Addenbrooke’s Hospital between September 2015 and January 2018. The database recorded information regarding incidents of missed radiological abnormalities and the appropriate action instituted.  Addenbrooke’s Hospital’s Electronic Patient Record System (EPIC^Ò) was used to gather information on the demographics of the patients. The Chi square test was used to compare the frequency of discrepancies.

Results: 96 incidents of missed radiological findings were identified in the database during the study period. This signifies a missed abnormality rate (as recorded by the database) of 0.49% (96/19493). Paediatric abnormalities were more commonly missed than those in any other age group. Abnormalities of the spine were found to be the most frequently overlooked, with a total discrepancy rate of 1.81% (6/332). The clinical consequences of the missed findings were variable with 36.5% (n=35) of the cases requiring ‘advice only’, 32.3% (n=31) were referred to the fracture clinic, and 18.8% (n=18) required a return visit to the ED. When examining the recording of data, a delay of 1.25 days occurred between the publishing of the radiological report and the identification of the missed abnormality. The entry of data was heavily dependent on the consultant completing the ATT shift, with an average of 0.21 abnormalities logged per shift. 

Conclusion: The system in place for the review and recording of missed radiological abnormalities at Addenbrooke’s ED is a key safety process. The process of logging incidents should be made simpler to allow maintenance and internal auditing of this safety-net. The results show that there are certain anatomical regions which are associated with a higher number of missed abnormalities, as are paediatric injuries and thus care should be taken in interpretation of these X-rays.. Enhanced teaching in these areas is suggested. 

Background: Penthrox is an inhalational anaesthetic, increasingly being used in UK Emergency Departments for rapid analgesia. Currently, Penthrox is used for reduction of dislocated joints and fractures. This study aimed to demonstrate the efficacy of Penthrox as an analgesic agent used in such procedures, and to show if Penthrox can reduce the use of opiates.

Methods: Retrospective study used with data derived from a UK tertiary care centre, with 175 data points spanning from 17/07/2017 to 10/01/2018. The data was analysed for medical condition, complications, resolution of the condition, and other analgesics.

Results: The data demonstrated that dislocation reductions under Penthrox had a 73.5% (n=49) success rate; fracture reductions had a success rate of 69.0% (n=42). In 10.9% (n=55) of dislocation reductions and 50% (n=84) of fracture reductions Penthrox was used only as an adjunct. The rate of use of opiates for dislocation reductions was 7.27% (n=55) for successful reductions; 21.8% for unsuccessful reductions. In the cases in which Penthrox was used as an adjunct, opiate use was 5.45%. For fracture reductions, opiate use was 9.52% (n=84) for both successful and unsuccessful reductions; however, in the cases where Penthrox was used as an adjunct, opiate use was 35.7%. Reporting of side effects could have been confounded by the complex nature of many cases observed e.g. polypharmacy masking potential harms.

Conclusions: Penthrox demonstrates promise as an effective analgesic for dislocation and fracture reductions. A number of data demonstrated that Penthrox is used as an adjunct rather than a primary analgesic. If the efficacy of Penthrox was better know by practitioners, this could reduce the use of opiates in the ED setting for such minor procedures. In addition, future studies could focus on comparing the efficacy of Penthrox to the current sedation regime for treatment of dislocations and fractures.

Background

Our hospital has a virtual fracture clinic system, where patients with fractures are referred to a vetting system in the first instance. X-rays and notes are reviewed by a consultant  and follow-up at an appropriate time interval is arranged.

At a meeting, a comment was made about the poor quality of note keeping in hand injuries which often resulted in patients being brought back for early review to ascertain function.

A retrospective review of the notes of adult patients presenting with hand injuries over one week was undertaken to determine the standard of documentation.

Results

50 consecutive sets of notes were reviewed. Patients were seen by a range of clinical staff: consultants 4; ST4-6 or senior clinical fellow (SCF) 6; ST1-3 or junior clinical fellow 5; GPST 2; FY2 or ENP 32; other 1.

Injuries included lacerations, incised wounds, blunt trauma and fractures.

Hand dominance was documented in 17 of 50 (34%). Some documentation of function was noted in 20% of patients. Specific tendon function (where applicable) for digits and thumbs was recorded in less than 10% of patients, and motor and sensory components of ulnar and medial nerves with sensation in median nerve distribution was recorded specifically in 1 patient. Capillary refill was not recorded in any patient.

Discussion

Detailed documentation for hand function was very poor in the sample reviewed. This is a small sample although capturing at least 20 different practitioners. 

Hand injuries clearly form a large part of our minor injuries workload, with 50 patients identified in under one week. Although defined as a minor injury, hand injuries have a major impact on a patient’s ability to undertake activities of daily living and to work. Under appreciated functional deficits can have long term and far reaching consequences for individuals.

The presumption following this audit was that the deficit is in standard of recording rather than examination. However, a brief on-line survey was carried out to determine staff level of confidence in hand examination.

This was completed by a range of staff including consultants, all grades of medical staff and ENPs.  64% of respondents stated they were either extremely confident or very confident in hand examination. However, 6% were unable to examine flexor digitorum superficialis, and 85% felt they would benefit from further teaching on hand examination.

In view of the above findings, a tick box proforma was developed to document hand examination with the aim of improving documentation, and acting as an aide memoire for essential history and examination findings. This has been recently introduced. In addition, a new teaching session on detailed examination of digits and hands has been developed and is being delivered to all grades of staff.

Re audit is currently ongoing, but initial assessment suggests overall standard of documentation ahs been improved.

Background:In2014,UK’s National Institute for Health and Care Excellence(NICE),updated its guidelines for head injuries and has lowered the threshold for requesting CTscans in patients on anticoagulation.In this update,NICE has suggested that all patients who had head injuries and are on warfarin,who do not have any other indications for CTHead scans,should have a scan done within 8hours of presentation.Eventhough this guideline is for patients on warfarin,in practice,in most centres,this has resulted in CTscans being performed for all patients on any anticoagulation with head injuries.Due to the increase in head injuries from falls &increased use of anticoagulation in elderly patients,larger number of CThead scans have been performed in this age group.Hence there is a need to validate this guideline.Therefore,in this study,we looked into the clinical outcome and CThead findings of anticoagulated elderly patients over85years of who sustained head injuries.Methodology:In This study,the first100 anticoagulated head injury patients>85years of age,undergoing CThead scans from ED,in a district general hospital,from1^stNov2016were included and their electronic records were reviewed.Those with incomplete records were excluded.Approval from the institution's audit committee and clinical effectiveness lead were obtained.Results:Out of the100patients included,42 were male&58 were female.1 patient,who was on warfarin,had to be excluded due to incomplete records.91patients sustained head injuries following falls,6 had head injuries after collapsing episodes and2 patients presented due to long lie& head injuries.87.9%had GCS15 at presentation,12.1%had GCS between9/15-14/15, none had GCS8or less,none had motor vehicle accident or other forms of major trauma.88CThead scans were either normal or showed age related chronic findings.8scans showed old cerebral infarction,1 had intra-parenchymal bleed,1 revealed subdural haemorrhage and1 had sub arachnoid haemorrhage.72 patients were on warfarin,25on NOAC's and2were on enoxaparin.All 3patients with intracranial bleeding were discussed with neurosurgeons and managed conservatively,1patient was on warfarin,1was on NOAC and another was on enoxaparin.The patient with intraparenchymal bleed died in a week’s time.Following the scans,43 patients were discharged fromED,42were admitted under the medical team,11 under surgical team&3 were admitted under orthopaedics due to associated bone injuries.INR reversal with Beriplex was done for 2patients in ED.Following admission,51 patients were discharged from hospital,4died in hospital and 1was transferred to another care facility.Of the87 patients with a presenting GCS of15,65 were on warfarin&21 were on NOAC&1on enoxaparin.In this group,only 1patient onNOAC had subarachoid haemorrhage,rest of the scans were negative for intracranial bleed.Amongst the remaining12 patients with a presenting GCS between14-9,7were on warfarin,1on enoxaparin &4 were on NOAC.Using regression analysis,it can be predicted that there is<1%chance that elderly patients with head injuries on warfarin or NOAC with GCS15 at presentation will have intracranial bleed on CTscans.The chance of intracranial bleed for those presenting with GCS14-9was16.7%.Conclusion:This review found that only3%of CThead scans,on elderly anticoagulated head injury patients,had evidence of intracranial bleeding.Since this small study found that there is<1%chance that elderly patients with head injuries on warfarin orNOAC with GCS15 at presentation will have intracranial bleed on CTscans,it is really worthwhile that multicentric studies with larger number of patients are carried out before blindly subjecting all elderly orally anticoagulated head injury patients,with normal GCS without any other indications for CTscans,to unnecessary radiation exposure.  

The year of 2017 had several worldwide catastrophes to account for. Portugal was one of the countries that most suffered from major fire events. A lot of lives perished during the referred year. Nevertheless, this unfortunate event provided our teams with a unique expertise used recently - January of 2018 in a mass burn casualty. An Urban fire evolving a local gathering centre, during a card playing contest.

Retrospective analysis of data from the national medical emergency institute allowed the access to the time line of the events; namely from the first call, to the first ambulance on scene, the time of activation of the national crises coordination centre, the advanced life support on scene, the search for ICU beds with burn and ventilator capacity; the decision on secondary transportation and finally the data from hospital concerning results on mortality, duration of hospital stay and mobility.

This record showed the interoperability between institutions from fire-fighters to law enforcement as well as all the clinical link from pre-hospital to definitive care. From a total of 42 victims, classified initially with the start triage as 7 red, 15 yellow, 12 green and 8 black, ended as 10 non-hospitalized patients, 2 patients with a less than 24h hospital stay; 9 patients admitted to surgical yards with an average hospital stay of 5 days. Eleven critical care patients, ventilated. From these 9 were air transported to central Hospitals, and 2 transferred by ambulance.  There was a 40% in-hospital mortality, related to the severity of the burns and a high morbility.

Reviews must be done more often as debriefing after the event isn´t enough to support the activity nor the will to improve of teams. Much concern has to be taken how critical patients are handled from the first responders to definite care, recording procedures is of extreme importance. Tragic events must push countries into upgrading their medical emergency capacities.  

This records showed the interoperability between institutions from fire-fighters to law enforcement as well as all the clinical link from pre-hospital to definitive care. From a total of 42 victimes, classified inicially with the start triage as 7 red, 15 yellow, 12 green and 8 black, ended as 10 non hospitalized patients, 2 patiens with a less than 24h hospital stay; 9 patients admitted to sururgical wards with an avarage hospital stay of 5 days. Eleven critical care patients, ventilated. From these 9 were air transported to central Hospitals, and 2 transfered by ambulance.  There was a 40% in-hospital mortality, related to the severity of the burns and a high morbilidty.

Reviews have to be done more often as debriefing after the event isn´t enought to support the actiyity nor the will to improve of teams. Much concern has to be taken how this critical patients are handled from the first reponders to definite care. Much has to be recorded. Tragic events must push countries into upgrading their medical emergency capacities.  

Introduction

Recreational party drugs can lead to hospitalisation through clinical effects as well as causing potential secondary toxicity due to adulterants. In late 2017 a cluster of ED presentations occurred in regional Australia due to toxicity attributed to “blue superman”, a form of MDMA. Presentation occurred due to those using experiencing clinical effects which were more sedative than stimulant in nature. Biochemical analysis of several of the tablets transported to ED with the cases confirmed the presence of alprazolam, one of the more toxic benzodiazepines.

Methods

Cases of “blue superman” exposure were identified from having been either reported to the Hunter Area Toxicology service (HATS) for clinical consultation, or via a computer surveillance of ED triage at state level which identified “blue superman” as the reason for presentation. Information on the former was extracted from the HATS database whilst that of other cases was extracted from digital medical records. Data collected included demographic details such as age and sex, as well as clinical details such as mode of hospital presentation, presentation Glasgow Coma score (GCS), length of stay and any available biochemistry relating to the presentation.

Results

In total 20 cases were identified all occurring over a 20 day period in late 2017. Of these 17 (85%) were male and median age was 22 years (range 18-33). Ambulance transport was used in 14 (60%) of cases. Australian Triage Scale (ATS) category 1 was given to 2 cases (10%), ATS 2 to 7 cases (35%) and ATS 3-4 for the remainder. The main reason for presentation was a decreased level of consciousness with the median presentation GCS being 11 (range 5-15). Median length of stay was 9 hours (range 3-16) No patients required endotracheal intubation. 

Serum alprazolam levels were available in 10 cases with median level 55 microg/L (Clinical use reference range 5-50 microg/L). Serum alcohol levels were available in 8 of these cases with a median value of 33.8 mmol/L (range 0 – 47.6 mmol/L).

Conclusion

Our study reinforces the dangers associated with recreational drug use and how clinical effects may differ from that expected.

Background

Children under the age of one represent a vulnerable population, frequently presenting to the emergency department (ED) in times of illness or injury. A thorough assessment including consideration of non-accidental injury and child protection is vital. The Royal Alexandra Hospital, Paisley (RAH) is a district general hospital in the West of Scotland with an ED that sees over 65,000 patients every year, 0.3% of whom are under the age of 1 and present with an injury. A local review in 2011 found that 77% of these young injured patients were not being appropriately examined, having child protection risk factors assessed or being discussed with a senior emergency physician. An ‘Under 1 Injury Proforma’ was subsequently introduced. This study aims to ascertain if introduction of this proforma has improved the care of injured children under the age of 1 within the emergency department.

Methods

Retrospective analysis of clinical notes in a single site district general hospital in the West of Scotland.  Inclusion criteria were children under the age of one presenting to RAH ED with an injury between 1^st January 2017 and 31^st June 2017. Patients were identified from electronic note systems ‘Trakcare’ and ‘Portal’. Those with illnesses and planned returns were excluded. If notes were not available, these patients were also excluded. Data was collected and analysed on Microsoft Excel. 

Results

98 patients fulfilled the inclusion criteria and 77% of these were assessed using the ‘Under 1 Injury Proforma’.  Head injuries accounted for 76% of presentations; limb injuries 10%; burns 6%; wounds 4% and bites 2%. The mean age was 7 months (range 1-11 months). For 16% of patients, the assessed attendance was their second visit to the ED with an injury and this formed part of the child protection screen. Specific red flags and concerns were identified on the proforma in a further 5%. Overall 29% of patients were discussed with social services and 13% discussed with the health visitor. This resulted in 93% of patients being discharged home with the remaining 7% being admitted for both medical and/or social reasons.

Conclusion and Discussion

Introduction of a proforma for assessment of the injured child under the age of one has improved care within the emergency department. Child protection ‘red flags’ are more frequently assessed in this vulnerable population and discussions with health visitors and social services are more frequently documented. Whilst many studies agree that children under 1 are most commonly the victims of severe abuse¹, others point out that children remain exceptionally vulnerable and at high risk of non-accidental injury at least until the age of 2^2,3,4 and even until age 5⁵. We plan to extend this study to look at the assessment of children aged up to 2 years and consider the introduction of an ‘Under 2 Injury Proforma’ in place of existing documentation.

Introduction: Deep vein thrombosis occurs in 84 people per 100,000¹.  DVT remains a serious cause of morbidity and mortality with 40% of untreated proximal DVT’s leading to clinically significant pulmonary embolism². NICE Guidelines for diagnosis of DVT recommends using clinical risk stratification, followed by high sensitivity D-dimer and venous ultrasound Doppler as appropriate. The aim of our study was to examine if we were appropriately following most current guidance. 

Methods: The study was conducted in the emergency department of a large teaching hospital. All ED referrals for venous ultrasound doppler between January 1^st, 2017 and July 1^st, 2017 were collected. Patient’s notes were obtained along with lab results and vascular lab reports. The patients Well’s score, D-dimer and Doppler result were recorded.   

Results: 202 patients had Doppler scans performed during our seven month period. 27 Doppler’s were positive for lower limb DVT, 13 of these were proximal (6.4%), all patients with proximal DVT had a wells score of 2 or higher. 61 patients had no wells score documented. 97 patients (48%) did not have D-dimer performed as per guidelines. No Patients had repeat scans on review.

Conclusion: We are not adequately following the NICE guidelines for the diagnosis of lower limb DVT. As a result, our rates of positive Doppler scans is much less than similar studies on Irish ED populations (6.4 vs 12.4%)³. No patients were brought back for review meaning that all our below knee DVT’s were being treated as aggressively as above knee.It is a regular occurrence in Ireland that patients do not have immediate access to Doppler scanning and have to be treated with anticoagulants until DVT can be definitively excluded. As a result of our poor compliance with decision-making tools and our aggressive treatment of below knee DVTs, we are unduly placing our patients at increased risk of complications caused by this unnecessary anticoagulation therapy.

Sudden cardiac arrest is a leading cause of death. Outcome after SCA is dependent on critical interventions; particularly effective chest compression, early defibrillation, and advance life support. Training schoolchildren to perform cardiopulmonary resuscitation is possible method of increasing bystander CPR rates. The American Heart Association (AHA) recommended that cardiopulmonary resuscitation (CPR) training for schoolchildren to be mandatory.

Objective: To evaluate a video base training and a new, 1-hour, a condensed training program to teach cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills to a cohort of school students.

Method:

Study design- prospective, Interventional trial;

Study population- students from primary 5^th and 6^th grade;

Study setting- private school (English program)

Study protocol- approved by the school. Students' attitudes, prior experience and baseline knowledge were sampled using an initial questionnaire and CPR video training and a modified American Heart Association (AHA) CPR/AED pre-test. Students received training in continuous chest compression CPR and AED. A modified American Heart Association (AHA) CPR/AED test was immediately tested. One month and one year later, were retaken. Examination score differences were analyzed using matched paired t- tests. All tests were two tailed with alpha set at 0.05. Confidence Intervals (CI) 95% were calculated as appropriate.

Results:

Forty three subjects completed the program (P5=25, P6=18); mean age 11.5 years old; 67.4% female. Following initial video base training, the mean score= 5.45/7 (77.86%) demonstrated proficiency in CPR and AED knowledge. Subjects also shown by scores on a modified AHA based written exam (60.9% versus 77.3%;p= 0.00). At one month and one year demonstrated knowledge retention in similar test.

Discussion & Conclusions:

All training interventions are successful within a short time scale in increasing knowledge of the children when tested. Training should start at and an early age and be repeated at regular intervals over the school career. Thai students have the potential to train CPR and AED use very well.

Introduction: Resuscitation of septic patients by means of one or more fluid boluses is recommended by guidelines from multiple relevant organizations and as a component of surviving sepsis campaigns. Controversial results from the recently completed FEAST (Fluid Expansion As Supportive Therapy) trial in African children have raised questions about the use of intravenous bolus fluid for the treatment of shock. Hence, it is necessary that the effect of fluid bolus therapy which is conventionally used in cases of sepsis be reassessed in the context of the Indian population.

Aims and Objectives:

1. Establishing the beneficial effects of Fluid Bolus therapy (FBT) in Sepsis.
2. Demonstrating adverse effects of initial fluid bolus therapy, if any, in the Indian population.

Materials And Methods:

Study design: Hospital Based Retrospective Observational Study

Study area: Department of Emergency Medicine, ICU and General wards of Columbia Asia Referral Hospital, Bangalore, India

Sample Size: All cases that met the selection criteria as per standard definition of Sepsis during the study period have been included in the study (N=170).

Exclusion Criteria:

i)       Age <16 years

ii)     CCF

iii)    CKD

Working Definition:

Fluid bolus Therapy: For the purposes of this study a fluid bolus is defined as a volume of a defined fluid administered at presentation to ER over 3 hours time period as mentioned in the notes of the treating doctor in the EMR of the hospital.

For comparison of proportion, Chi square test is being used. A p-value <0.05 is considered statistically significant.

Results: Among the patients (n=170: male-98 female-72) examined, the mean duration of stay was 7.5 days (SD 4.8) while the ICU stay was 3.8 days (SD 3.6) and mortality of 10.59%. Primary source of Sepsis was Uro (38.8%) followed by Pulmonary (26.5%). The mean volume of FBT was 1.53L (SD 0.52). Mortality was 19.5% in patients administered RL while 7.8% in those administered NS. However, there is no significant association between choice of fluid and volume of fluid bolus with the mortality (P>0.05).

Conclusion: The initial results of this on-going study hereby validate the routinely exercised practise of fluid bolus therapy in patients of sepsis. However, unless this study is carried forward prospectively in a multi-centric trial we cannot conclusively negate the possibilities of any adverse effects of FBT in sepsis, thus, opening up a new perspective in the treatment guidelines of Sepsis.

Aims

Apparent life threatening events (ALTE) describe a non-specific group of symptoms, frightening to the on-looker, comprising a combination of apnoea, colour change, marked change in muscle tone and coughing or gagging. Occuring in children under 2, ALTE are concerning for both caregivers and professionals due to the event itself and the possibility of a serious underlying cause. It is essential to correctly identify an ALTE event at first contact in order to evaluate and manage appropriately. This study aimed to examine the level of awareness of ALTE among medical practitioners on the front-line.

Methods

A survey available both online and on paper was undertaken in a UK district general hospital with 6000 live-born infants per year. The emergency department (ED) is a mixed adult and paediatric environment. It was available for a 4-week period to all paediatric department and ED doctors and nurse practitioners likely to be involved in early assessment and management of these patients.  Respondents were screened initially to determine who had an awareness or knowledge of an ALTE presentation in children; these then answered further questions about investigating and managing a neonate (up to 28 days old) presenting with ALTE who appeared well on examination using a typical scenario.

Results

33/83 practitioners responded to the survey (40% response rate). 30 participants returned usable questionnaires, but not all had all every single question answered - denominators reflect this. 17 (57%) were from paediatrics and 13 (43%) from ED.

21/30 (70%) were aware of ALTE as a presentation and therefore completed the full survey. Awareness was significantly higher in those working in paediatrics compared to ED (15 (88%) vs 6 (46%), p 0.02) There was a weakly positive correlation between time from graduation and increased awareness in those who provided this information (N = 26, R = 0.22, p 0.27).

Evaluation of knowledge showed 18/21 (86%) correctly identified risk factors for increased concern requiring closer assessment and investigation. There was inconsistent recognition of ALTE symptoms/signs (as per ICD-10 criteria) with no respondent recognizing all features (range of correct recognition (13-20/21 (62%-95%). However, up to 11/21 respondents (52%) incorrectly attributed other common symptoms to an ALTE presentation.

Discussion

This is a small local survey. However the participants are representative of those likely to be involved in the early management of infants with suspected ALTE. Awareness was significantly higher in those working in paediatrics compared to ED

Conclusion

There may need to be improved education and supervision, especially of junior doctors in ED, when assessing young and vulnerable infants. A larger, multicentre study will help clarify just what is known, and how education might be better delivered.

Background

Educating lay public is one of the strategies to improve survival after out of hospital cardiac arrest. Schoolchildren are an easily accessible population to be taught basic life support (BLS) and use of an automated external defibrillator (AED) and can be regarded as multipliers of knowledge, potentially reaching the whole population. Slovenian legislature recommends BLS and AED courses in schools but a need for a structured and effective nationwide approach remains. 

The aims of our study were: a) to examine the state of knowledge and attitudes towards BLS and AED among schoolchildren and b) to test the appropriateness and effectiveness of theBLS and AED course with a developed questionnaire.

Methods

Centre for Emergency Medicine of the Maribor Health Centreorganized a 2-hour BLS and AED course for seventh and ninth grades of elementary schools in Maribor. Three schools were included in the study based on their application in the time frame of the study (November to December 2017). First part was an interactive lecture by an emergency physician. Second part was a practical workshop, where each student practiced on their own manikin. A training AED was used. To test the appropriateness and effectiveness of the course protocol we developed a specific questionnaire examining knowledge and attitudes about BLS and AED. The answers were recorded immediately before and after the course. Results were described with descriptive statistics and statistical significance analysed with paired t-tests.

Results

One hundred and seventy-two students were included, of whom 116 were seventh-graders and 56 were ninth-graders. In the knowledge part of the pre-test, 4 out of 10 items were incorrectly answered by more than half of the students.  There was a statistically significant improvement in all knowledge items on the post-course test except in one item regarding the phone number in case of a medical emergency, which was well known before the course already. The attitude towards BLS and AED was mostly favourable even before the course, except in 5 items regarding self-efficiency and fear. Post-course, a positive shift in attitudes was observed in all items, reaching statistical significance in all but 3 items.

Discussion and Conclusions 

The state of knowledge of BLS and AED in the examined population was not surprising considering current legislature. However, the attitude towards the subject was surprisingly favourable. As expected, a progress in knowledge and attitude was observed after the 2-hour course confirming appropriateness and effectiveness of the course protocol. These findings confirm an immense potential of teaching schoolchildren as was previously reported and suggested by the international “Kids Save Lives” campaign. The acquired knowledge and shift in attitude should, however, be tested after a few months period to test the long-term effects of the proposed protocol. Based on those findings, a proposal could be made to enforce inclusion of BLS and AED course in mandatory school curricula.

Ethical approval and informed consent: not needed.

Background

Ketamine is widely used for Emergency Department (ED) paediatric procedural sedation (PPS). Although serious adverse events are rare, vomiting is seen in 3.8% to 18.7% of cases, with a higher incidence in older children.  Anti-emetics are regularly prescribed to prevent emesis in other situations including anaesthesia.

To determine the current level of evidence regarding the use of anti-emetics to prevent vomiting in ketamine PPS we developed a three-part question and literature search.

Clinical scenario: A 6-year-old with a laceration presents to your ED.  He is a suitable candidate for ketamine PPS.  As emesis is a recognised side-effect you wonder whether a prophylactic anti-emetic would reduce his chance of vomiting.

Methods

In [children under 18] undergoing [ketamine procedural sedation] does the administration of [prophylactic anti-emetic reduce the incidence of vomiting]?

Pubmed, Cochrane Library, Medline and Elsevier were searched for studies in children aged 0-18 in which ketamine and anti-emetics featured.

Results

42 papers were found. 37 were irrelevant and 1 of insufficient quality for inclusion. 

Two open-label randomised controlled studies (Lee et al, 2012; Lee et al, 2014) demonstrated no significant difference in emesis between intramuscular ketamine alone or with oral anti-emetic (metoclopramide or ondansetron respectively).  Both studies, however, have significant limitations.  Oral anti-emetic was given concurrently with intramuscular ketamine without taking into account differing bioavailabilities.  Children who required a second dose of ketamine were excluded.  And both studies only included younger children (under 5 and under 6 respectively) in whom vomiting is less common.  The two groups in Lee (2014) were not well matched with a higher mean age in the ondansetron group; as older children are more likely to vomit this questions validity of their results. 

Two studies showed a beneficial effect of anti-emetic in intravenous ketamine PPS.  

In a prospective double-blind randomised placebo-controlled trial, Langston et al (2008) demonstrated significantly lower emesis with ondansetron (4.7%,n=128) compared to placebo (12.6%,n=127,p=0.02) with a number needed to treat (NNT) of 13 (95%CI,7-91). On subanalysis of children older than five (n=95), NNT dropped to 8 although confidence intervals were wide (95%CI,5-34). Study limitations include possible selection bias due to convenience sampling and the routine use of glycopyrrolate.

In a multicentre prospective cohort study in which 3916 children received intravenous ketamine, Bhatt et al (2017) demonstrated that pre-procedural anti-emetics significantly reduced emesis (OR 0.5;95%CI,0.4-0.7,p<0.0001).  Further analysis demonstrated significantly higher vomiting in children who received pre-procedural opioids (OR 1.42;95%CI,1.05-1.92,p=0.02).

Discussion and conclusion

Although two studies did not demonstrate reduced emesis in PPS with anti-emetics, these studies both had significant limitations raising questions about the applicability of their results. Two well designed studies both demonstrated prophylactic anti-emetics significantly reduced vomiting in children receiving intravenous ketamine, more significant in older children and in those receiving pre-procedural opioids.  Bhatt’s study in particular has external applicability to other EDs internationally as sedation episodes from six EDs were included in analysis.

The clinical bottom line is that ondansetron should be considered when using intravenous ketamine for PPS, especially in older children or those who have received pre-procedural opioids.

Electrical injury is a rare but destructive type öf injury that might have a high mortality and morbidity rate and causes damage to many systems of the body. The origin of the electrical current may be natural, or a man-made material. Electrical current in the nature is in the from of lightning and its mortality rate is quite high.

Electrical injury is seen especially among working individuals. Damage in the tissue depends on the current, type of exposure, resistance of the tissue and duration of contact and it affects various systems such as Cardiovascular system, nervous system, gastrointestinal system, musculoskelatal system and skin.

Aim: To analyze demographics and laboratory data of the patients admitted to Thé Emergency Medicine Clinic of Ataturk Universty School of Medicine Hospital with the complaint of exposure to Electrical current and lightning strike.

Findings and Result: 320 patients who were admitted to the Emergency Medicine Clinic of Ataturk Universty School of Medicine Hospital with the complaint of exposure to electrical current and lightning strike, and were diagnosed to have electrical injury between January 1st, 2006 to November 6th, 2016 were included in the study.

16.9% of the patients were female and 83.1% were male. Mean age was 24.01+- 14.59 years. Among the patients 48.4% lived in rural area and 51.6% lived in the and city. When we look at the type of the injuries, 46.6%, 45.6% and 7.8% of the patients suffered low voltage, high voltage and lightning, respectively. Exposure to electrical current was the most frequent in August; 76.2% of the patients had burns in the body; 27.5% had blunt trauma and ECG of all patients were obtained. Duration of hospitalization was found to be 10.12+- 18.82 days. Presenting GCS, type of admittance, number of concultations in the emergency department, presence of blunt trauma and duration of hospitalization were significantly different in different types of events  (p <0.001). Mean CK and myoglobin levels were higher than the upper limits of the laboratory. CK-MB and troponin I values were also significantly different among all the groups.

Introduction: In severely injured patients, hemoglobin is an important factor in the initial work up as well as in monitor. The reference hemoglobin level measurement technique remains the automated laboratory-analyser using a venous blood sample which is a precise, reliable and reproducible technique. However, it requires a needle stick and results can be delayed. Thus, during the last few years, new techniques have developed to allow an immediate bed-side measure of hemoglobin levels that is both non-invasive and of acceptable precision according to the majority of validation studies.

The aim of this study is to affirm the precision of non-invasive hemoglobin measurement device by comparing the results obtained with those to the reference method in severely injured patients admitted to the Emergency department.

Materials and Methods: An observational prospective study that included all severely injured patients (Based on Vittel Criteria for sever trauma) treated in the ICU of our emergency department. We conducted a bedside measure of the hemoglobin using the portable Pronto Pulse Co Oximeter Masimo (SpHb) as well as the conventional laboratory based measure (CBC). Both measures were conducted simultaneously. The management (Transfusion or not) was left up to the treating physicians, non blinded by the results. Statistical analysis used the SPSS and the coefficient of correlation (r).

Results: 44 patients were included, mean age was 38 ± 16 years of which 97% were of male gender, who simultaneously underwent 71 blood samples (CBC) and 71 SpHb measurements. The majority of patients were victims of Multiple Vehicle Accident). Within our patients, 34.2% had head injuries 20% of which had severe head injuries (OTI), 20.5% had abdominopelvic injuries and 18.2% had thoracic injuries. In our sample of patients, only 1 patients received a blood transfusion and required an urgent surgery (Within 24 hours). 43,2% of patients were kept in the emergency department for surveillance, 45,4% were admitted to ICU department, 2,3% to orthopedics department, 4.5% to Neurosurgery, 2,3% to General Surgery and 2,3% (1 patient) taken directly to the operating room (OR). The mean levels of hemoglobin were 12.94± 2.19 g/dL on CBC and 13.28 ± 1.92 g/dL on our device, with results obtained in 72± 39 minutes and 16± 11 seconds respectively. The coefficient of correlation between the hemoglobin level on CBC and the SpHb (r) was 0.839 (p< 0.001) with a median difference of -0.4 g/dL (-1, 0.5).

Conclusion: The non-invasive measurement of hemoglobin levels using the portable device is a new promising and appealing technology with its noninvasive feature, the possibility of continuous monitoring and particularly the rapidity of the results. In our sample of patients, it seems precise and well correlated to the reference laboratory-based results and thus could be reliable in the surveillance and management of severely injured patients.

Background

Acute Abdominal Pain (AAP) is one of the main symptoms at the ED. In-hospital mortality rate of AAP (5,1%) is much higher in comparison with chest pain (0,9%). There is an established therapy path for patients with chest pain, including biomarker determination and the monitoring at a chest pain unit. AAP is a multifaceted symptom with a wide variety of differential diagnoses. There is no official guideline for a diagnostic pathway for this interdisciplinary symptom. There is the need to analyse potential key performance indicators for AAP in the ED and improve the quality of diagnosis and initial treatment with the aim to decrease mortality. These data can be used to set up a clinical pathway “abdominal pain unit”.

Methods

We conduct a retrospective analysis of our routine data of 2015 to examine the patient flow in our ED for patients with AAP. We analyse the process times for critical diagnostic steps for patients with atraumatic AAP at our ED. Actually, we present data from a pre-analysis random balanced sample of 48 patients, half male and female. All patients had the triage category orange and yellow, according to Manchester Triage System. Statistical analysis is performed using SPSS.

Results

From 48 analysed patients, 41,7% were admitted to the hospital, 54,2% remained as outpatients and 4,1% left without been seen. The main diagnoses were gastritis and gastroenteritis (22,9%), acute pancreatitis (8%) and cholecystolithiasis, choledocholithiasis and nephrolithiasis. 43,8% of patients underwent diagnostic imaging, 70,0% of admitted and 26,9% of outpatients. The mean length of stay (LOS) in the ED was 353min. The median time to abdominal sonography was 319min, to abdominal CT 463min and to abdominal X-ray 236min.

Conclusion

Our data show that patients with AAP have a considerable high rate of abdominal imaging and a relatively long time until it is performed. Once confirmed in a larger data-set, we propose that early abdominal sonography (within 60min of arrival) should be prospectively tested to improve outcome.

Objective:  Despite popular consideration as a non-problematic drug in acute intoxication, cannabis plays an important role in emergency department presentations arising from recreational drugs. In this study we analyze the clinical characteristics of lone cannabis intoxications with or without alcohol and compare these two modalities.

Material and methods: 
Type of study: An observational study of medical records. The chi-square test was used to analyze categorical data.
Scope of study: Emergency department presentations to a tertiary hospital
Subjects: Any patient presenting to the emergency department with symptoms of acute intoxication caused by a recreational drug (in this case, cannabis associated with or without alcohol). We reviewed a specific database of patients with acute recreational drug toxicity from the 1^st of October 2013 to the 30^th of April 2017.

Results:  Of a total of 740 patients treated for recreational drug presentations, 220 (30%) included cannabis. In 140, cannabis was the only substance without taking into account ethanol. In 12 cases the concomitant consumption of alcohol was not reported and therefore the remaining 128 were analyzed. Of these 128, 77% were male. 80 (62%) had consumed alcohol, as well as cannabis. Clinical characteristics and physical examination were compared in both groups.  Thus in cannabis only / cannabis plus ethanol (expressed in percentages) tachycardia was obtained (27% / 25%); decreased state of consciousness (8% / 39%); hypertension (13% / 10%); hypotension (4% / 9%); vomiting (6% / 25%); anxiety (48% / 24%); hallucinations (10% / 3%); agitation (15% / 13%); psychosis (21% / 5%); seizures (2% / 1%); palpitations (17% / 6%); chest pain (6% / 0%) and headache (0% / 3%). There were no deaths, arrhythmias, hyperthermia or need for intensive care in any of the groups investigated.
Of the above variables, there were significant differences between the two groups (p> 0.05) in the following: the state of consciousness, vomiting, anxiety and psychosis.

Conclusions: Among drug related presentations, cannabis is present in a significant proportion. Although these are not severe presentations, they do present symptoms that carry a significant burden of care in the emergency department. The most prevalent symptoms are anxiety, decreased state of consciousness, tachycardia, agitation and psychosis. In pure cannabis intoxication, neuropsychiatric symptoms are more prominent (anxiety, psychosis); when alcohol is coingested, decreased level of consciousness and vomiting are significantly more frequent.

Introduction:

The management of patients with acute heart failure (AHF) in the emergency department (ED) is a real challenge as many as other pathologies leading to an acute respiratory distress (ARD) especially with hypercapnia. In asthma and chronic obstructive pulmonary disease (COPD) exacerbations, hypercapnia was associated with poor prognosis.

The aim of the study was to evaluate the prognosis value of hypercapnia in AHF patients admitted in ED.

Methods:

An observational prospective study during one year (march 2017 to February 2018).

Inclusion of adult patients admitted in the ED with ARD (defined as PaO2 less than 60 mm Hg) due to an AHF. COPD patients were excluded.

Patients were divided in two sub-groups: hypercapnic patients(HC): PaCO2 more than 45mmhg and normo or hypocapnic(NH) : PaCO2 less or equal to 45mmhg.

A standardized management was performed for all patients including oxygentherapy and/or non invasive ventilation according to indication, hemodynamic  treatment with nitrates and diuretics according systolic blood pressure (SBP).

Early prognosis was evaluated according to intensive care unit admission, recurrence and mortality at one month.

Results:

Inclusion of 174 adult patients. Mean age :69 +/-10 years. Sex-ratio=1.

Demographic and  co morbidities data were similar for the two groups  except for renal failure which is more common in NH group than in HC group respectively 30 versus(vs) 11 (p=0.005). clinical and biological characteristics of HC group vs NH group were: Median Glasgow coma score (GCS) = 11 vs 13 (p=0.005); Mean SBP= 181±47mmHg vs 157±38mmHg(p<0.001); Mean pulse oximetry(SPO2) = 71±17 % vs 83±13% (p<0.001). Mean PH=7.2±0.15 vs 7.38±0.1; Blood lactate (BL)  = 4.8±3.5 mmol/l vs 3±2.5 mmol/l . After standardized treatment , SBP, respiratory rate, SpO2 and BL are similar in two groups.

We don't found any difference the prognosis of HC group vs NH group(n) : intensive care unit admission : 5 vs one (p0.07), recurrence in 10 vs 7 (p=0.1)  and mortality at one month: 4 vs 3 (p=0.4).

conclusion:

 Acute hypercapnia in patients admitted to ED for AHF don't influence the early prognosis and mortality of patients admitted in the ED. 

Background

In prehospital care, in the city of Sibiu and its surroundings, acute pulmonary edema (APE) is a growing major emergency that requires rapid intervention.

The purpose of the study was to correlate the incidence of APE diagnosed patients according to their type of pulmonary edema (cardiogenic, infectious or mixt), but also by age group, risk factors, environmental origin, patient gender and treatment in a time frame of 2 years and 3 months. 

Materials and methods

The study was performed through a retrospective observational method on a number of 1931 cases that occurred to SMURD MIC Sibiu between 01.01.2016 – 31.03.2018, out of which 93 cases were of APE.

Results

Out of a total of 93 patients with APE, 39 patients (41.94%) were in 2016, 45 patients (48.38%) were in 2017, and 9 patients (9.68%) were in the first 3 months of 2018.The months with the highest incidence of APE cases were December, January, March and May, accounting for 55.91% of all cases. Distribution by gender: 47 women (50.53%), of whom over 70 years were 37 patients (78.73%), between the ages of 50 and 69 years there were 9 patients (19.14%), between the ages of 30 and 49 years there was only one patient (2.13%) and 46 men (49.47%), of whom between 50-69 years there were 23 patients (50%), over 70 years there were 20 patients (43.47%), between the ages of 30 and 49 years there were 3 patients (6.53%).

The risk factors involved in the occurrence of APE from the point of view of their incidence were: hypertension of all stages respectively AHT stage III: 49 patients (52.68%), stage II: 18 patients (19.35%), stage I: 6 patients (6.45%) and 11 patients with heart attack (11.82%). From the point of view of the home environment, the number of patients living in the urban environment was 60(64.52%) and 33 patients were living in the rural environment(35.48%).

Conclusions

From the point of view of risk factors, it was found that ATH was the first cause of pre-hospital APE, especially ATH stage III, possible consequence of inappropriate treatment. Paradoxically, although in most cases heart attack has APE as a direct complication, in this study the complication was observed in only 11 patients out of the total of 93 cases of APE . 

Most patients diagnosed with APE lived in an urban environment and most certainly had other factors contributing to the diagnose, such as sedentariness, air pollution, stress, diet or smoking. 

Interestingly, the highest incidence of APE was found in women over 70 years, as opposed to the age range of 50 to 69 years for men. Romania being a 4-seasons country, the study showed the unfavorable influence of the cold seasons, namely winter and spring, on the hypertensive and cardiac patients.

Objectives: To report a case with dynamic ST segment elevation suggestive of antero-septal acute myocardial infarction (AMI) that proved to be bilateral pulmonary thromboembolism (PTE).

Case report: A 37-year-old woman with chest pain was transferred to cardiology department. Findings from the out of hospital electrocardiogram were suggestive of antero-septal AMI. Catheterization revealed non occlusive coronary disease. Transthoracic echocardiography showed an elevated pulmonary and right heart pressures. A chest CT scan confirmed the diagnosis of bilateral PTE.

Conclusion: This case emphasizes the role of evolving electrocardiographic changes in the diagnosis of PTE, particularly in patients with chest pain and ST segment elevation suggestive of acute coronary syndrome.

Acute urinary retention in a district general hospital: an observational study

Background: Our district general hospital sees an average of 102,000 acute emergency attendances a year. Acute Urinary Retention (AUR) is a common and distressing medical emergency presenting with painful inability to pass urine which can be relieved by catheterisation.

Objective:  The objective of this observational study was to assess and audit the management of AUR in the emergency department (ED) against Royal College of Emergency Medicine (RCEM) clinical standards.

Method:

This retrospective study was carried out over a six months period from July 2016 to early January 2017. Data was obtained from electronic records and patients’ notes.

Results:

In the 52 adult participant patients, the mean age was 71 and median 73 years. Upon arrival 12% received analgesia and only 38% were catheterised within one hour of arrival. Initial catheterisation was done mainly by any available doctor and a few trained nurses. However, by the second hour only 64% had been catheterised. Altogether 72% received a urethral catheter and 68% appropriately received antibiotics. While 85% had residual urine documented, only 15% had their renal function tests documented. 94% had outpatient follow up or specialty (urology) review in accordance with local policy upon leaving the department.

Discussion and Conclusion:

This single centre, retrospective study demonstrates a snap shot of the challenges of managing AUR at a district general hospital.  Our department has since then embarked on shared learning events (meetings and e-mail) on the study results to highlight the relevance of early intervention (analgesia and catheterisation) and introduced a departmental protocol. On-going education and training is required to maintain reasonably good clinical standards of care.

Introduction: Acute urinary retention (AUR) is a common presentation in the ED. Admitting patients who present with AUR is costly and uneconomical. Evidence based guidelines have shown that these patients who are discharged do equally as well as those who are admitted. 

Methods: The study looks retrospectively at the 6 month period from 01st January 2017 to 30th June 2017, looking specifically at males who presented with acute urinary retention. The process involved reviewing individual patient notes, observations and National Early Warning Scores (NEWS) to ascertain the need for admission. 

Results: During the six-month period, 88 incidences of AUR presented to the ED. 32% of presentations were due to BPH. The second most common cause was constipation, 22%. Urinary tract infections accounted for 16% of presentations. In total 72% of patients were admitted to the ward, 8% discharged with no follow-up, 8% discharged to follow-up by GP, and 12% discharged for urology follow-up. 66% of patient admissions were deemed unnecessary. 59% of patients who were admitted passed TOV first time and 60% of those discharged passed TOV first time. Tamsulosin status was also reviewed, showing that 22% of patients were initiated on Tamsulosin at time of presentation. These patients went on to greater TOV success than those who were not given the drug. 

Conclusion: The nightly bed cost for admitted patients in Greater Glasgow & Clyde in 2016 was £562.29. Of the 41 patients who were admitted unnecessarily, a collective 78 days were spent in hospital costing £44,983.20. The projected yearly cost of these unnecessary admissions would be £83,088 - a huge, unnecessary financial burden. Following this analysis, management of male patients presenting with AUR to the ED has been altered. Patients who are well can now be discharged with catheter in situ and Tamsulosin, with a return urology appointment. By stream-lining this service, patients do not require lengthy hospital stays.

Objectiv: The artery of Adamkiewicz is the most important supply feeding the lower thoracic, lumbar and sacral portions of the spinal cord. Because of very little collateral circulation in this area the injury to this artery can cause dramathic consequential neurologyc damage. It is characterized by the loss of motor function below the level of injury, loss of pain and temperature and preservation of fine touch, vibration, proprioception and urinary sphincter disorders. Due to the rare occurance of the spinal stoke that is not perioperative related and the flaccid paraplegia in the patients that arrive in the emergency department, it is a great risk of mislead diagnostic of lumbar disc hernia.

Methode: We present 3 cases that came in our emergency department: 3 male, age 54-63-74, presenting flasc paraplegia installed within the last 24 hours. The 54 years old patient had no medical history, no chronic medication, just an unhealthy diet and a mild dyslipidemia. He was investigated and diagnosed in the first two hours from the arrival and he presented myocardial infarction with a very large thoracic-abdominal aortic dissection and lesions of artery of Adamkiewicz.He was sent for surgery. The 74 years old patient with medication for hypertension and prostate adenocarcinoma was sent to investigation that revealed that the cause of the paraplegia was not the tumoral compression but the occlusion of abdominal aorta and artery of Adamkiewicz. He was also sent for surgical desobstruction. They both survived surgery. The 63 years old patient came in the emergency department with flaccid paraplegia suddenly installed. He had been priory diagnosed with lumbar disc hernia and had antiinflamatory medication. He was incorrectly diagnosed with compressive lumbar disc hernia. He presented cardiac arrest and died in the emergency department in less than one hour from arrival. He was diagnosed postmortem with occlusion of abdominal aorta and occlusion of artery of Adamkievicz.

Conclusions: Occlusive vascular lesions affecting the spinal cord (spinal stroke) are diagnostic challenges. A very good understanding of the simptoms and a rapid diagnostic in the emergency department could save lives!

Background

Increased mortality related to differences in delivery of weekend clinical care is the subject of much debate.

Aim

We compared mortality following detection of acute kidney injury (AKI) on week and weekend days across community and hospital settings.

Design

A prospective national cohort study, with AKI identified using the Welsh National electronic AKI reporting system.

Methods

Data were collected on outcome for all cases of adult AKI in Wales between 1 November 2013 and 31 January 2017.

Results

There were a total of 107 298 episodes. Weekday detection of AKI was associated with 28.8% (26 439); 90-day mortality compared to 90-day mortality of 31.9% (4551) for

AKI detected on weekdays (RR: 1.11, 95% CI: 1.08–1.14, P < 0.001, HR: 1.16 95% CI: 1.12–1.20, P < 0.001). There was no ‘weekend effect’ for mortality associated with

hospital-acquired AKI. Weekday detection of community-acquired AKI (CA-AKI) was associated with a 22.6% (10 356) mortality compared with weekend detection of CAAKI,

which was associated with a 28.6% (1619) mortality (RR: 1.26, 95% CI: 1.21–1.32, P < 0.001, HR: 1.34, 95%CI: 1.28–1.42, P < 0.001). The excess mortality in weekend CAAKI

was driven by CA-AKI detected at the weekend that was not admitted to hospital compared with CA-AKI detected on weekdays which was admitted to hospital (34.5% vs. 19.1%, RR: 1.8, 95% CI: 1.69–1.91, P < 0.001, HR: 2.03, 95% CI: 1.88–2.19, P < 0.001).

Conclusion

‘Weekend effect’ in AKI relates to access to in-patient care for patients presenting predominantly to hospital emergency departments with AKI at the weekend.

Introduction: Turn-around-time (TAT) for medical imaging is a key determinant of emergency department length of stay (EDLOS). We conducted this study to measure changes in TAT and EDLOS by adding attending radiologist coverage overnight.

Methods: This study was conducted at a tertiary referral, academic medical center in an ED with 65,000 annual visits. In July 2017, the Department of Radiology and Medical imaging implemented overnight coverage with Board Certified Radiologists to produce final reads for radiology reports. Prior to July 2017, images acquired between 9PM and 6AM were interpreted provisionally by radiology residents, with final readings performed by attending radiologists the next morning. We measured the turnaround time for preliminary and final radiology reports, the number of patients discharged from the ED that need to be called back to the hospital for additional care due to changes in their radiology report, and the ED length of stay for patients treated overnight. Data collected from August through October 2016 served as the control group and from August through October 2017 served as the intervention group. Studies performed between 9PM and 6AM were included. Statistical analysis was performed using the Mann-Whitney U-test and the Yates-corrected Chi-Square test.

Results: The average time from completion of the exam to provisional read was 1.6 hours before and 1.3 hours after (p<0.01). The time to final read was reduced from 10.5 hours to 3.0 hours (p<0.01). The number of patients called back for additional treatment after discharge went from 12 before to 1 after (p<0.01). The time to radiographic clearance of the cervical-spine in trauma patients (n=244 before and n=273 after) went from 8.2 hours to 2.5 hours (p<0.01), allowing for removal of the cervical collar in most instances. The overall EDLOS for patients treated and released (n=325 before and n=353 after) went from 5.97 hours to 5.5 hours (p<0.01).

Conclusions: The addition of an attending radiologist to perform final interpretations of images between the hours of 9PM and 6AM results in significant reductions in time to final read, time to C-spine clearance, overall EDLOS, and number of call backs. In addition, the presence of the attending reduced the time to provisional interpretations. We recommend around-the-clock attending radiology coverage to improve throughput and accuracy.

Background

In Republic Of Moldova stroke is the third leading cause of death (159,1 : 100000). In 2016 were registered 9289 new cases of stroke. Prevalence of cerebrovascular diseases is 73837 (207, 7:10 000) and incidence is 26,1 per 10 000 population.

Materials and Methods

During one year there were analyzed 2805 calls of patients with Stroke (1.01.16 – 31.12.16), the average age 68,0±12,9 years, including women 53% (1487) and men 47% (1318). It was assessed the structure of stroke, diurnal and seasonal addressability and diagnostics which mimics stroke.

Discussion

 Ischemic stroke constituted 1983 (70,7%); 402 (14,3%) transient ischemic attack; 228 (8,1%) other diagnosis and sequel of stroke; 181 (6,4%) intracerebral hemorrhage and 11 (0,4%) subarachnoid hemorrhage. The study of diurnal  addressability attests us a high risk for days of Monday, Tuesday, Wednesday and Friday in which were registered 63% of total calls. The diurnal study attests that 55,4% from stroke appear between 08:00 – 16:00, 33,4% from 16:00 to 24:00 and 11,7% from the cases from 24:00 till 08:00 the morning. The study of  seasonal addressability attests a high risk for winter season with registered 27,2%, spring season 24,6%, summer season 24,7% and autumn season 23,5% from the total number of stroke.

Stroke is predominantly a problem of advancing age, the most affected categories of age are 60-69 years (23,5%), 70-79 years (33,1%) and patients over 80 years were 17,6%. The average length of call reception was 2 min, 46 sec ± 0,92 sec (interval 68 sec – 5 min 16 sec). During an hour from the appearance of symptoms 42,7% patients called. In 28,9% cases it was reported only one symptom, in 31,5% cases 2 and in 39,6% cases 3 and more symptoms. Only in 18,9% from the symptoms all  were present, words which indicated stroke, fact which speaks that only about 1 from 5 persons understands the stroke problem. The most frequent symptoms which were reported while calling to emergency were the speech disorder (27,3%)  paresis in limbs (19,8%), disturbances of consciousness (16,4%) and in 7,4% cases disturbed sensibility. The diagnoses which mimics stroke include: syncope 54 cases (1.9%), coma 46 cases (1,6%), sequel of stroke 75 cases (2,6%), epilepsy 28 cases (1,0%) brain and other tumor 20 cases (0,7%) and hypertensive encephalopathy 5 cases (0,2%). Of all cases of acute ischemic stroke of 1983 patients, time of onset greater thean 4.5 hours were in 834 (42%) patients and 597 (30.1%) patients with contraindication thrombolytic therapy.

Conclusion

In the RM only 27,8%  of stroke patients currently receive thrombolytic therapy, mainly as a consequence of delayed presentation to hospital. Informative programs for the population are required taking into consideration that only 1 of 5 patients that has reached the emergency services were aware of the problems and consequences caused by stroke. Stroke is predominantly a problem of advancing age, patients over 70 years were 1005 (50,7%). The most frequent symptoms were the speech disorder (27,3%),weakness or numbness of arm or leg (19,8%) and disturbances of consciousness (16,4%).

Admission Criteria For Intensive Care Unit In Poisoning Patients

Dilber UCOZ KOCASABAN, Yahya Kemal GUNAYDIN, Volkan ARSLAN, Mehmet OKUMUS

Introduction

In our country and the world, we come across poisonings as a serious health problem. There isn't any practical scoring system that can be used to evaluate this patient group. We believe that providing a scoring system for these patients is essential in determining need for intensive care, duration of follow- ups, mortality and morbidity rates. We aim to put forth objective criteria as is related to intensive care need in patients that present to the emergency department with a diagnosis of poisoning.

Material and Method

292 patients who were admitted to the intensive care unit between 2016- 2017 and were older than 18 years were included in the study. Ankara criteria was determined as the following; 1) GKS < 15, 2) low blood pressure (systolic < 90 mmHg), 3) bradycardia (<60 bpm) or tachycardia (> 100 bpm), 4) high lactate levels (>2,0), 5) acidic or alkali pH (<7,35 or > 7,45). We predicted that patients that met at least one of these criteria needed intensive care, while patients that didn’t meet any of them, didn't. Patients APACHEII, SOFA, QSOFA, MEWS and SIRS scores, duration of hospitalization, need for inotropes, dialysis, mechanical ventilation, special treatments and for antidotes were recorded and computer with the scores they got from the Ankara criteria.

Conclusion

We observed that there is a statistical correlation between the criteria we suggested and scoring systems such as APACHE II, SOFA, QSOFA, MEWS and SIRS (p <0.005). We statistically proved that patients who were hospitalized for 2 or more days, had need for inotropes, dialysis, mechanical ventilation, special treatment and antidotes met at least one of the Ankara criteria (p< 0.005).

DISCUSSION

The results of our study have shown that with criteria that we have put forth, there can be an objective assessment in regards to a patients need for intensive care.  We believe that the criteria, which consist of 5 criteria easily accessible in the emergency room, will not only prevent unnecessary intensive care unit admissions, but also be useful in predicting prognosis and mortality and morbidity rates.

Key Words: poisoning, intensive care, scoring

Introduction: Endotracheal intubation is a technique frequently performed in emergency department (ED), but it is associated with a high rate of immediate and severe life-threatening complications.

Objective: To assess the problems associated with endotracheal intubation in the emergency department, and difficulties in terms of immediate complications.

Methods: We conducted a prospective observational, monocentric study, involving adult endotracheal intubation over two years. Variables included demographic patient information, indications of intubation, methods, devices and drugs used, number of attempts, intubation success or failure, operator characteristics and intubation events.

Results: Inclusion of 137 patients. Mean age = 52±21years. Sex ratio = 1.49. Indications for intubation n (%): neurologic signs 71(52), respiratory disorders 38(27), hemodynamic 35(25), toxic 22(16) and cardiac arrest 17(12). Emergency physician managed all the intubations and most 97% were physician trainees. Rapid sequence intubation was the first method attempted in 91% of patients. Ethomidate was used in 76%, succinycholine in 76%, ketamine in 12% and propofol in 3% of cases. The evaluation of the number of attempt for intubation was performed in 88 patients (64%). First attempt in 47%, Second in 12%, Third in 3% and more than three in 2% of cases. The most frequent complications (18%) were hypotension 12%, bradycardia 3%, esophageal intubation 1.5% and selective intubation 1.5%. There was no death case registered.

Conclusion: Emergency physicians predominantly using rapid sequence intubation, and successfully manage the majority of emergency department intubation. Etomidate is the most common induction agent. Succinylcholine is predominantly used as selected neuromuscular-blocking agent. Reported intubation-associated adverse events occur in 18%.

Objective: Investigate the rate of adverse events in patients with acute heart failure (AHF) classified as having low risk by the MEESSI scale and discharged from the emergency department (ED) and determine the discriminatory capacity of this scale for these events in patients and associated variables.

Method: The risk of patients included in the EAHFE Registry was stratified using the MEESSI scale, and those classified as having low risk and discharged from the ED were analyzed. The adverse events analyzed were: all-cause mortality at 30 days (M-30d), revisit to the ED for AHF at 7 days (REV-7d), and revisit to the ED or hospitalization for AHF at 30 days (REV-H-30d). The area under the curve (AUC) of the receiver operating characteristic (ROC) was calculated. We also analyzed the relationship of 42 variables with RV-7d and RV-H-30d by multivariate logistic regression.

Results:  A total of 1028 patients were included. The M-30d was 1.6% (confidence interval 95%: 0.9-2.5), REV-7d was 8.0% (6.4-9.8) and REV-H-30d was 24.7% (22.1-25.7).  The AUC ROC of the MEESSI score to discriminate these adverse events was 0.69 (0.58-0.80), 0.56 (0.49-0.63) and 0.54 (0.50-0.59), respectively. The following variables were independently associated with RV-7d: chronic diuretic treatment  (odds ratio 2.45; 1.,01-5.98), hemoglobin <110 g/L (1.68; 1.02-2.75) and intravenous diuretic treatment in the ED (0.53; 0.31-0.90), while  peripheral artery disease (1.74; 1.01-3.00), previous AHF episodes (1.42; 1.02-1.98), chronic treatment with mineralocorticoid receptor antagonists (1.71; 1.09-2.67), Barthel index in the ED <90 points (1.48; 1.07-2.06) and intravenous diuretic treatment in the ED (0.58; 0.40-0.84) were associated with REV-H-30d

Conclusions: Patients with low-risk AHF discharged from the ED exhibit adverse events rates close to the internationally recommended standards. The MEESSI scale, however, does not adequately predict REV-7d and REV-H-30d. This study defines factors associated with these adverse events.

Introduction: Depression is the disease that contributes most to disability in the world (7.5%) while anxiety disorders is the sixth disease (3.4%). In addition, depression is the leading cause among deaths by suicide: 800,000 a year and will be the second leading disease worldwide by 2020.

Purpose: Evidence of distribution of depression in the world.

Methodology: This study is a literature review with data collected from the WHO and other national official websites of different countries, years 2017- 2018.

Results: Greenland is the country with the highest prevalence of depression 6.41%, USA 5%. Brazil 5.8%, Cuba 5.5%, Paraguay 5.2%, Chile, Uruguay 5%, Peru 4.8%, while Argentina, Colombia, Costa Rica and the Dominican Republic show 4.7%, Ecuador 4.6%, Bolivia, El Salvador and Panama 4.4%, Mexico, Nicaragua, Venezuela, Honduras 4.2%, Guatemala 3.7%. The prevalence rate varies in the world and ranges from 3.6% in the western Pacific region to 5.4% in Africa. In Europe, Finland with 5.19%, Sweden with 4.97%, Great Britain, Benelux countries, Germany, France and Portugal have a prevalence rate of 4% - 5%. Spain with 2.4 million cases of depression in 2015, Germany with 4.1 million, Italy with 3.04 million and France with 2.9 million. According to Our Word in Data (2018), Colombia is the country with the lowest depression level worldwide, followed by Albania (2.4%) and Poland (2.48%).

Conclusions: Developed countries have the highest prevalence of depression. Countries with the lowest prevalence of depression are the Balkan and Eastern European countries, where prevalence ranges between 2.5% and 3%.

Background

Alcohol-related harms arising in the Night-Time Economy (NTE) impose a substantial burden on ambulance, police and hospital Emergency Departments. Alcohol Intoxication Management Services (AIMS) have been implemented in the NTE areas of some towns and cities in the UK and abroad in an effort to reduce use of emergency services.  AIMS provide basic care for intoxication and minor injuries and may be a place of safety for patrons of the NTE who are unable to look after themselves. However, it is not known whether AIMS are an acceptable intervention to those who are treated there.

Methods

 As part of a large multicentre evaluation of the effectiveness and cost effectiveness of AIMS this study explored the experiences of attending an AIMS and examined the acceptability to their users. A sequential mixed methods approach including interviews and a survey was undertaken involving a convenience sample of adults (>18) who attended six different AIMS in the UK between June 2016 and October 2017. 

Results

Telephone semi-structured interviews were undertaken with 19 AIMS users (12 Male, 7 Female) and 208 surveys were received (53.2% male, 46.8% female, 57.5% aged 17-24 years, 24.5% aged 25-34 years and 17.0% aged 35+ years) The majority of  survey respondents (57.2%) indicated their AIMS attendance was intoxication-related. A sizable proportion of interviewees were workers in the night time economy who had suffered an injury.

The majority of survey respondents (67%) rated their overall experience of AIMS as 10/10, with a further 30% rating it 7-9/10. Survey and interview findings were consistent and showed AIMS care was a highly acceptable intervention for their users.  All aspects of care received in the AIMS were regarded positively, especially the caring and friendly approach of staff.  If the AIMS had not been available a third (31.3%) of survey respondents indicated that they would have been unsafe and a minority (14.9%) said they would have contacted emergency services or gone to the ED (24.4%). This suggests only a minority of AIMS users were potentially diverted from the ED.

Discussion and conclusions AIMS offer a highly acceptable intervention to all their users regardless of intoxication or minor injury.  To our knowledge, this is the first study to explore the experiences of AIMS users so provides new evidence for emergency medicine practitioners, researchers and decision makers considering implementing AIMS.  For the latter particularly, while only a minority were likely to be diverted from using emergency services, it is important to consider potential unmet social need around the safety of patrons in the NTE.  Although AIMS users expressed high levels of satisfaction with their care, these additional AIMS services may be addressing unmet social demand rather than diverting ED demand. This evaluation will provide vital effectiveness and cost-effectiveness evidence to shape any future decisions around the implementation of AIMS.

Background

Chest pain was the most common reason for acute hospital admission in the UK in 2017, however most of these patients do not transpire to have acute coronary syndromes (ACS). Measuring cardiac troponin concentrations is central to the diagnosis of acute myocardial infarction (AMI) by the universal definition. However, the turnaround time of laboratory assays is 45-60 minutes, not including transport time. This is the niche that point of care (POC) troponin assays have sought to fill, aiming to rapidly rule out ACS thereby improving patient care and increase efficiencies in the acute care setting.

We aimed to evaluate the diagnostic accuracy of the Alere Triage Cardio3® POC cardiac troponin assay in patients presenting to the Emergency Department (ED) with suspected ACS, using cut-offs set at the limit of detection (LoD) and 99^th centile upper reference limit (URL) of the assay.

Method

This was a planned sub-study of the multi-centre prospective observational Bedside Evaluation of Sensitive Troponin (BEST) study. Patients were prospectively enrolled in 8 hospitals across England on presenting to the emergency departments with symptoms suggestive of an ACS. Patients were excluded if they had another medical condition requiring admission or the peak symptoms were >12 hours ago. Written consent was obtained for each patient and ethical approval from the Health Research Authority was obtained (14/NW/1344).

Blood samples were drawn at 0 and 3 hours, they were analysed with the Alere POC cardiac troponin I (cTnI) assay. The 99th centile is 0.022ng/ml and the LoD is 0.01ng/ml.

The primary outcome was a diagnosis of AMI, adjudicated according to the third universal definition. Reference standard cardiac troponins measured at was used and measured at 0 and 3 to 6 hrs.

The sample size power calculation was 605 patients, assuming an outcome prevalence of 10% and that the lower 95% confidence interval of a sensitivity of 100% should be 90%.

Results

We enrolled 500 patients, of which 432 had an admission sample (62 with AMI) and 382 (59 with AMI) had a 3-hour sample for analysis. Using the admission sample, POC cTnI had a sensitivity of 79.0% (95% CI 66.8 – 88.3%) and a specificity of 95.3% (92.4 – 97.4%) at the conventional 99^th centile cut-off. Using the LoD as a cut-off yielded a sensitivity of 83.9% (72.3 – 92.0%) with specificity 91.9% (88.3 – 94.6%).

With the 3-hour sample, sensitivity at the 99^th centile was 88.1% (77.1 – 95.1%) with specificity 94.9% (91.7 – 97.1%). At the LoD, the sensitivity was 94.9% (85.9 – 98.9%) with specificity 91.8% (88.1 – 94.7%).

Conclusion

Our findings show that the Alere Triage Cardio3® POC cTnI assay has optimal sensitivity using the LoD cut-off with sampling 3 hours after arrival. However, as over 5% of AMIs would be missed, this strategy should not be used alone to ‘rule out’ AMI. Further research should focus on utilisation alongside validated decision aids.

Background

Supplemental oxygen is a fundamental treatment for the prevention of life-threatening hypoxia in the pre-hospital environment. However, the use of pressurized oxygen cylinders entails a significant logistical burden, especially within a military setting, due to their size, weight and requirements for safe transport and storage. With technological advances in this field, the aim of this literature review was to determine the evidence base for alternative delivery devices for the provision of supplemental oxygen in pre-hospital care, particularly within austere and remote environments.

Methods

A literature review was undertaken of PubMed, The Cochrane Library and military specific publications for English language studies between 2000 and 2018. Search terms used were combinations of “oxygen” AND “concentrators” OR “devices” OR “generators” AND “pre-hospital” OR “austere”. The primary outcome was reported use of an alternative supplemental oxygen delivery device in the pre-hospital environment. Secondary outcomes included the demographics of location used, functionality and oxygen rate and flows.

Thirty-nine research articles met the search criteria. Those studies that did not meet the study question were excluded as well as those relating to the use of home oxygen concentrators. Eleven articles were found that examined the use of alternative sources of supplemental oxygen in an “austere” clinical environment. These studies were subsequently analysed by two independent reviewers with relevant data collected separately using a pre-determined form.

Results

The articles examined looked at a wide range of alternative supplemental oxygen devices. Seven papers related to use in the austere military setting, two to use at high altitude and two papers assessed function in a high temperatures and high humidity environment. A single paper examined a new concept of alternative chemical oxygen generation; however, this had not yet progressed beyond laboratory experimentation.

The results highlighted that oxygen concentrators may offer a viable alternative supplemental oxygen supply in the austere environment. Two papers reported logistical savings compared to oxygen cylinder use, with one study demonstrating a four-fold reduction in costs while maintaining an oxygen supply that was “just as effective and reliable.” At present it was found that chemical oxygen generation would not meet user requirements, though further concept study in this area was continuing.

Overall, there is paucity of literature examining the use of oxygen concentrators to supply supplemental pre-hospital oxygen, with the majority of studies focusing on use in a remote operating theatre setting. Additionally, there is only a single study, which examined the use of sole battery supplied oxygen concentrators, something that would be an essential requirement in the pre-hospital setting.

Conclusion

Though the consensus in the present literature is supportive of oxygen concentrator use and offers much promise, there are a number of key areas relating to performance and longevity that need to be addressed before replacement of pressurized oxygen cylinders can take place in the austere clinical environment.

BACKGROUND AND OBJECTIVES: In the UK, there are clear guidelines for paramedics on how to treat patients presenting with prolonged convulsive seizures. Despite this, paramedics have reported feeling unsure about determining the severity of seizures and often rely on senior paramedic experience as opposed to published guidelines. To determine individual paramedic action in this scenario, a questionnaire was developed. The responses were then compared to national guidelines to determine whether there were any significant differences.

METHODS: An anonymous online questionnaire comprising of ten questions was created via an online survey tool in December 2016. All responses were automatically saved by the tool and then analysed by May 2017. A volunteer sample of 138 paramedics from seven ambulance services across the UK chose to complete the questionnaire after being informed about it by their ambulance service.

RESULTS: Paramedics who completed the questionnaire mostly acted in concordance with UK guidelines, although when regarding more complex seizure management, there were some responses which differed from the guidelines significantly. Many paramedics offered suggestions on how to improve ambulance care of patients presenting in this way, with the most frequent suggestion being the stocking of buccal midazolam, alongside undertaking more training, improving the clarity of ambulance clinical practice guidelines and being provided with more information about the patients. Buccal midazolam was also considered the easiest route of anticonvulsant administration for patients of all ages.

DISCUSSION AND CONCLUSIONS: In this sample, paramedics seldom had midazolam available to use, and practice varied with regard to which medication to use and when at various stages during the treatment of prolonged convulsive seizures. More needs to be done, such as exploring the possibility of stocking buccal midazolam in ambulances, to ensure optimal patient management and outcomes to reduce the incidence of status epilepticus and keep people with prolonged seizures out of hospital.

Background

Ammonia is the product of the catabolism of proteins. When level is too high, ammonia is toxic and generates multiple disturbances in brain, glucose level and metabolism. Diverse pathologic situations can cause a hyperammonemia, particularly liver failure. But many other causes, less known, can induce this kind of trouble as valproic acid, salicylate, pathologies of the urea cycle, of the fatty acid oxidation or of the amino acid transport, and organic acidemia. Over the last 20 years, scientific publications tried to attract attention of practitioners on hyperammonemia in adults and the other causes than liver failure. In January 2018, a 20 years old woman was admitted in the emergency department (ED) for vomiting and abdominal pain. A confusion rapidly occurred and then a coma with recurrent hypoglycemia. Medical history reported a less strong but similar event the year before, necessitating an inhospital treatment during 2 days for what seemed to be an unusual gastroenteritis. In our ED, this patient had an ammonia level at 177 (N=[11-51]). She was transferred in an intensive care unit (ICU) and after resolution, a deficit  of the fatty acid oxidation was found. After this case of rare hyperammonemia, we decided to analyze the practices concerning demands of ammonia level analysis in our ED during the year 2017.

Methods

We performed a data extraction of ammonia analyses realized over the year 2017 in our hospital. We excluded the analyses realized for patient under 15 years old, for external institutions or for patient not admitted through ED. Then we separated patients in 2 groups: the analyses asked by the emergency department and the analyses asked by the intensive care unit (ICU) or other services (OS) for patients previously admitted in the ED. Then we compared the 2 groups in terms of level of ammonia, confusion, treatment with drugs inducing hyperammonemia, acute or chronic liver failure, anomalies in glycemia and septic status.

Results

108 ammoniac level measures were performed in the hospital laboratory. 46 were excluded. 24 had been asked by the ED, 36 by the intensive care unit and 2 by other services, for 35 patients : 18 patients in the ED, 15 in the ICU, 2 in other services. For 6 patients, measure was made again in the ICU. Levels for patients admitted in ICU were higher (116 [22-679] vs 51 [16-121] (ED) and 33 [31-35] (OS)). Over the 15 patients admitted in the ICU from the ED without a measure of ammonia, 8 had a pathologic level and all had one factor among confusion, drug at risk or liver failure.

Discussion

These results corroborate the hypothesis that hyperammonemia is not enough evocated as an etiology in confusion in our ED, even for severely ill patients with comorbidities associated with this metabolic disturbance. Publications are very few in the emergency medicine field. A prospective study is being prepared to obtain stronger data about the accuracy of a systematic measure of ammonia level in confused adult patients.

Objective: The aim of our study was to evaluate the chance of successful manual defibrillation according to AMSA value and others CPR indicators during OHCA due to VF.

Methods: An observational study on OHCA comprising VF patients (age ≥18) was conducted between July 2014 and April 2015. Patient ECG records registered before each defibrillation and AMSA values were analyzed. Patient specific data were collected from the emergency forms. Data was analyzed using Statistica, version 8 (StatSoft, OK, USA) and statistical significance was set at p<0.05.

Results: The cohort of 46 subjects was analyzed. 45.65% presented ROSC due to successful defibrillation. From a total of 176 defibrillation attempts, AMSA proved significantly higher values on subjects with successful defibrillation (p<0.05). Data analysis between time to ALS (≤ 5 minutes and > 5 minutes) resulted to be statistically significant in the survivor group (p= 0.0043) and in the non-survivor group (p=0.0247). Most of the patients (75%) with optimal mean arterial pressure (MAP) to maintain cerebral circulation required administration of 1-3 mg of adrenaline.

Conclusions: In order to attempt defibrillation and appreciate the early prognostic of OHCA patients, a decision making score could be established based on the analysis of AMSA, myocardial and cerebral dysfunction indicators (low adrenaline dosage, optimal MAP after ROSC) and individual factors (ALS ≤ 5 minutes, bystander CPR).

Study objectives: The opioid epidemic is devastating to our society and will likely require a multifaceted approach to defeat.  Numerous federal, state, and local initiatives have been suggested to collectively combat this disease.  Our study analysis a simple and economically neutral local approach to assist in this process.

Methods: A retrospective, cohort observational study.  Location: suburban teaching hospital with an annual census of 90,000 patients. Care plan were initiated for patients flagged by ED staff as concerning for drug seeking behavior.  An ED administrator then collaborated with the patient’s primary physician.  If the primary doctor agreed, a care plan was initiated, which typically eliminated narcotic utilization or prescribing.  Patients subsequently received a certified letter regarding their plan.  Care plans were stored alphabetically in a central storage area, divided into three sub-groupings based on last name. The first 40 patients in each group were included for analysis.  Charts were flagged electronically when patients presented to the ED.  ED Visits were determined one year prior, and for five consecutive years following initiation, based on letter posting date.  Exclusion criteria: unclaimed letter, incomplete data, or non-drug seeking care plan. Statistics: Two-tailed Wilcoxon signed-rank test with significance of p<0.05.  This study was approved by our IRB.

Results:  One hundred and twenty patients were analyzed and 12 were excluded.  Exclusion basis: incomplete data (N=4), did not receive letter (N=2), and non-drug seeking care plan (N=6).  This left 108 patients for analysis.  Mean age was 39.7 years, (IQR 25-55 yrs).  Male gender comprised 53% of sample population (N=58).  Overall, there were 825 visits prior to study care plan implementation and 62 during the fifth year (p=< 0.0001).  Mean yearly ED visits prior to care plan initiation were 7.6 (95% CI 11.9-3.3).  Mean visits following implementation were: one year, 2.3(95% CI 4.3-0.3); two years,1.3(95% CI 2.7-0.0); three years, 1.1(95 % CI 3.1-0.0); four years, 0.8 (95% CI 2.1-0.0); five years, 0.6 (95% CI 1.7-0.0). The five-year total mean reduction in visits was 7.0 (95% CI 8.1- 6.2) (p=<0.0001). The mean reduction of visits 1 year following implementation was 5.3 (95% CI 6.1- 4.3) (p=<0.0001) and between years one and two was 1.2 (95% CI 2.14-0.27) (p= 0.0002).  An insignificant reduction in visits occurred from two to three (0.2) (p=0.08), three to four (0.2) (P=0.82), and four to five years (0.2) (p=0.29). 

Conclusion:  Care plans are effective way to reduce ED visits in patients with drug seeking behavior and can likely assist in combatting this epidemic.

Background: Pulmonary embolism (PE) is an obstructive disease of the pulmonary arterial system caused by the embolization of thrombus originating from the deep veins of the lower extremities. Almost 25% patients of PE present with sudden cardiac death and not all patients may have classical symptoms. Hypercoagulable states have been reported to cause cerebrovascular and myocardial thrombosis but rarely PE.

Methods: We present a case of a 27 year old male who presented to the Emergency Department with complaints of low backache and giddiness. Patient was found to be tachycardic, tachypneic and in shock.  Patient had a low probability of PE with a Well’s score of 1.5 but was diagnosed as having Massive bilateral acute pulmonary embolism with deep vein thrombosis secondary to Protein C deficiency.

Results: Patient underwent urgent bedside echocardiography and computed tomography pulmonary angiography (CTPA) and was thrombolysed in the ED before being shifted to the Cardiac care unit for further management. He was kept on anticoagulants and other supportive medications. The stay comprised of ICU and room care and the patient was discharged in stable condition after 7 days.

Conclusions: It is imperative for emergency physicians to have a high index of suspicion in young patients presenting with atypical symptoms and low clinical probability for PE in order to thrombolyse the patient on time.

Farm accidents in Ireland have increased by 13% in the last 5 years and by up to 31% in the last 10 years (TEAGASC, 2018). Portiuncula University Hospital is based in Ballinasloe a semi-rural town in the west of Ireland. There are approximately 8,500 farms in its catchment area. The Emergency Department registers over 26,500 patients annually approximately 10% of these are seen by the Advanced Nurse Practitioners (ANP). The aim of this study was to assess farm related injuries for the 9 month period from the 1^st July 2017 to 31^st March 2018 that were suitable for treatment by the ANP.

A retrospective audit of this cohort of patients was carried out by recording the Gender, Age, type of complaint, mechanism of injury, body part affected and treatment on an Excel spread sheet over the 9 month period.

78 farm related injuries were deemed suitable for treatment by the ANP. The majority of patients were male 65 with 13 female patients. Most of the patients 55 were in the 16-64 age group with 11 in the 65-74, 3 in the 4-16 and 9 were over the age of 75. The most common mechanism of injury was blunt trauma 24 followed by fall 22 and laceration 17. Of the 78 patients, 36 of them were discharged after treatment, 24 were brought back for review in emergency department, 13 were referred on to orthopaedics, and 4 were referred to the plastics team while 1 patient was referred to the surgical team for admission.

Injury prevention cannot be overemphasised. The need for improved support and education of farmers and staff about mechanism of prevention and health safety measures was highlighted. All age group are affected and included farmers; their children and staff. The audit also reflected the age profiles of patients and the possible link between medical comorbidities and risk of falls which influence the type of farm activity.  Further study is envisaged in this area. The study has influenced Patient Information Leaflets on reducing risk while carrying out various farming tasks.

The Emergency Department (ED), Portiuncula University Hospital, provides a 24 hour 7 day week Emergency Service to approximately 26,500 patients annually. The role of the Advanced Nurse Practitioner (ANP) in Minor Injuries supports the Emergency Medicine programmes key priorities of patient streaming and minimisation of delays for patients.

The aim of this audit was to identify the prevalence of minor sports injury with a view to identify opportunities for health promotion/education and enhance the ANP service.

617 patients were treated by the ANP service for the study period Jan 1^st to March 31^st 2018. 60 patients attended with a documented sports related injury. This pilot audit data included the age, gender, specific sport and patient disposal was carried out and will continue for a further nine months to allow for seasonal analysis.

60 new patients presented following a sports injury. The patients ages ranged from 4 to 43 years, with a gender difference of 22% female and 78% male. The most common sport causing injury was hurling/camogie, at 38%. Of these finger/thumb/hand injuries accounted for 70% presentations. Soccer was the second most frequent sport involved accounting for 32% of presentations with the largest proportion of these being ankle (37%) and knee (16%) injuries. Rugby accounted for 15% presentations with an equal number of lower limb and head injuries. The least common sport resulting in injury/presentation was horse riding at 5%. 68% of the patients were discharged, 10% were seen back at the ED review clinic whilst 18% required an orthopaedic clinic appointment and 3% orthopaedic care.  

The low prevalence of sports injuries over this 3 month period is likely multifactorial with harsh weather conditions causing cancellations of many sporting events. This is further supported by the fact that hurling/camogie (out of season) presentations accounted for over twice the number of rugby (in-season) related injuries. Similar to other Irish studies hurling and camogie account for a significant per cent of finger/hand related injuries. It highlighted the need for more in-depth history taking and study to include compliance with sports specific & sporting organisation specific safety standards entrenching appropriate warm-up and equipment. These will inform future patient education and health promotion strategies, which are an important aspects of the ANP role.

This winter saw the biggest surge in ED attendance due to Influenza. It was also the first winter that testing for Influenza was routinely carried out in the RAH ED. Clyde developed a standard operating procedure for influenza testing and Health Protection Scotland provided a summary on the guidance for anti-viral medication for Influenza. Patients that are in an at-risk group should be tested, and, if positive, admitted and given anti-virals. The aim of this audit was to follow up patients that had a positive influenza test in the RAH ED to determine if they were treated according to protocol.

Methods

All patients attending one teaching hospital between 21/12/17 – 04/01/18 on which a viral gargle for Influenza was preformed were included in the study. Those with a positive Influenza test were followed up on Clinical Portal using their CHI numbers. Variables recorded included sex, age, if Tamiflu was given, level of care, length of admission and if the patient was discharged from the ED. Those patients that were discharged were followed up in Clinical Portal to determine if they were in an at-risk group.

Results

80 viral gargles were performed and 44 of these were positive for Influenza. Of the 44 positive patients, 38 were admitted to hospital and 6 were discharged. Of the patients admitted to hospital, 31 were given Tamiflu, 3 were not and 4 were unknown. Of the 6 discharged patients, 4 were given Tamiflu and 2 were not. Influenza A was the most common type of influenza detected and the mean length of stay was 2.75 days. This was the same for all influenza types. Age did not affect length of stay.

Discussion

The 6 patients who had a positive viral gargle and were discharged were not treated as per protocol. 2 of these patients were not in an at-risk group so shouldn’t have been tested for influenza. 4 of these patients were in an at-risk group so should have been admitted for anti-virals. All admitted patients should have been prescribed anti-virals but 3 were not treated as per protocol. 7 patients in total were not treated as per protocol. This audit demonstrates the need to ensure that all staff are familiar of new protocols when are they are implemented. This can be a challenging task in an area such as ED where there is a high number of staff employed.

Background Cardiopulmonary resuscitation (CPR) is likely to be inappropriate for patients who are approaching the end-of-life and who then go on to have an out-of-hospital cardiac arrest (OHCA). Attempts at CPR upon such patients may be unwanted and may lead to a range of significant harms. Since 2006, General Practitioners (GPs) have been financially incentivised via the Quality and Outcomes Framework to develop end-of-life-care (EoLC) registers on which to record information regarding patients considered to be in the final 12 months of life. Once identified, eligible patients can then be offered additional supportive care as part of an Advance Care Plan, which may incorporate decisions about ‘do not attempt cardiopulmonary resuscitation’ (DNACPR). Anecdotal evidence from local paramedics and Emergency Department (ED) staff suggests that a significant proportion of patients eligible for EoLC are not being identified by their GP. The consequence is that at the end of their life, emergency CPR and ED transfer is often undertaken, which is not in the best interests of the patient. The aim of this study was to identify the number of patients transferred to the local ED with CPR in progress who were eligible for inclusion on an EoLC register.

Methods An audit reviewed the medical records of OHCA patients with CPR in progress who were brought into the ED of a district general hospital in the North West of England from 1st April 2016 to 31st March 2017. Records were compared against the Gold Standards Framework Proactive Indicator Guidance (GSF PIG), an evidence based guide used by clinicians to facilitate earlier identification of patients who may be approaching the end-of-life.

Results Of the 86 cases identified, 39.5% (n. 34) met GSF PIG Indicators, all of whom had resuscitation efforts terminated in the ED. GSF PIG indicators are divided into two categories, which are ‘general indicators of decline and increasing needs’ and ‘specific clinical indicators related to 3 trajectories’ (1. cancer, 2. organ failure and 3. frailty, dementia and stroke). Results showed that 94.1% (n. 32) of patients meeting GSF PIG criteria had general indicators of decline and 91.2% (n. 31) of patients meeting GSF PIG criteria presented with specific clinical indicators. Frailty was the most prevalent disease state (76.5% (n.26)), meanwhile, 61.8% (n. 21) of frailty patients presented with additional significant comorbidities. Within the cohort of patients meeting GSF PIG criteria, 8.8% (n. 3) had formally recorded a choice for no further active treatment so they could focus on maintaining an acceptable quality of life, yet no DNACPR had been recorded.

Conclusions The audit results show that approximately 4 out of 10 OHCA patients presenting to the ED with CPR in progress were eligible for inclusion on an EoLC register.  This suggests that GPs in the locality may need assistance from the wider health and social care community in identifying those patients in their care who may be approaching the end-of-life. We are currently evaluating the contribution that paramedic pathways may make in identifying and sign-posting eligible patients for additional support.

Background

Effective teamwork and communication is vital to provide effective patient care and also to maximise training opportunities for junior doctors.  There are several guidance documents, from the Royal College of Surgeons of England (RCSEng), highlighting the importance of effective teamworking and communication in surgery.[i]^,[ii] 

We audited the performance of a general surgical department in a busy London district general hospital against several team working quality indicators proposed by the Royal College of Surgeons.

Methods

We designed and distributed a questionnaire, to assess seven different aspects of effective team working as described by RCSEng .  All the junior doctors (sub-consultant grade) were asked to complete the questionnaire.  Each participant had to assign a score between one and five for each domain being assessed.  The results were then analysed and presented at the departmental meeting.  Changes were made to the structure of handover and team ward rounds.  These changes ensured that there was specific time allocated for teaching, team feedback, discussion and the completion of work-based assessments.  The questionnaire was then redistributed to assess if there had been an improvement.

Results

85% (23/27) of junior doctors in the department completed the questionnaire.  The highest performing area was in establishing a strong ‘team identity’ (mean score = 4.2).  The poorest scoring domain was having the opportunity to engage in ‘constructive debate’ to improve performance (mean score = 2.9).  ‘Lack of meetings as a team’ was most often commented on as a contributor to poor team working. 

These findings were presented at the departmental surgical meeting and specific recommendations were made to improve the structure of ward rounds, incorporating defined training opportunities and time for feedback and discussion.  These changes were implemented and re-audited at three months.

There was an overall increase in scores across all domains.  The greatest improvement was in understanding the team’s ‘objectives’ and having ‘involvement in decision making’.

Discussion

Improving surgical team effectiveness is vital in order to provide optimum patient care and also to create a positive training environment.  This audit has shown that simple structural changes to the working day of clinical teams can have a positive impact on their team working effectiveness. 

1.       Background:

D- dimer assay is mainly indicated  as a  “Rule out “ test in the emergency department  when the pre-test probability of Venous thromboembolism is low.  NICE guidelines recommend the use of two-level Wells Score followed by a D-Dimer test can safely rule out VTE.  Inappropriate request of investigations, particularly D-Dimer test was unnecessary use of resources and causing delays in the definitive diagnosis and management.  False positive results can lead to the unnecessary further investigations and can impact on the patient care.

This audit will investigate the appropriateness of D-Dimer test use in in the Ipswich Hospital Emergency Department.

2. Patients & Methods :

Data was obtained on all the patients who had requests for D-dimers made in a 2 week period in the emergency department. Searched electronic case notes find the indication for the admission and subsequent test order. Analysed which patients had documented two-levels Well’s scores. Reviewed the outcomes of the investigations and diagnosis and categorised them on appropriateness of ordering the D-dimer test.

3.       Results:

116 patients had D-dimer tests requested in the emergency department over a 2 week period. Only 17 patients (24%) had documented two-level Wells scores, therefore were deemed to have appropriately requested D-dimer blood tests. 54 (76%) patients were deemed to have inappropriately requested D-dimer blood test.  For 45 (39%) patients we were unable to obtained the documentation notes therefore could not comment on the appropriateness of the investigation.

43 (37%) patients had positive D-dimer results.  Out of the positive results only 10 (23%) patients had documented Well’s scores.  5 patients had positive scan to reveal VTE, of which only had documented the Well’s score prior to scan.

4.       Discussion

The results reveal a high percentage of patients have D-dimer blood results requested in the emergency department without clear indication as to why this test has been requested therefore it is deemed as an inappropriate investigation.  For the test to be deemed appropriately requested patients had to have a suspected diagnosis of VTE and an appropriate two-level Well’s score documented. If a PE or VTE is suspected there should be a documented Well’s score in accordance to NICE guidelines which then guides the need for a D-dimer test to be performed.

Factors that may often lead to inappropriate requests for D-dimer are blood tests being requested based on presenting complaint alone before a full assessment from a clinician. This is often deemed as a time saving measure to have bloods returned within a 4 hour period.

The inappropriate ordering of blood tests is not only costly for the blood tests alone but can also lead further inappropriate admissions and investigations therefore leading to further costs.

Background The use of high flow oxygen therapy (HFOT) allows continuous delivery of desired oxygen concentrations despite high inspiratory flow rates. HFOT also offers a degree of continuous positive airway pressure (CPAP) effect by splinting the nasopharynx and providing low levels of positive end-expiratory pressure (PEEP). These benefits have seen an increase in its use in emergency medicine for patients presenting with acute respiratory failure (ARF) and other forms of respiratory distress. Integral to its efficacy, humidification of HFOT is required to prevent airway drying and ciliary dysfunction. Normal physiology provides an absolute humidity of approximately 44 mg/L. Absolute humidity levels must be maintained above 33mg/L in order to maintain optimal ciliary clearance. Many traditional high flow circuits are unable to provide humidification during patient transfer. Anecdotally, humidification is often ceased for patient transfers both within and from the emergency department. In a benchtop study, we aimed to determine the decrease in absolute humidity during delivery of HFOT after ceasing humidification, and the time taken for humidity to return to acceptable levels after humidification is recommenced.

Methods:  A combined relative humidity and temperature probe was affixed to the distal end of a humidified high-flow circuit (Optiflow™ Fisher & Paykel Healthcare, East Tamaki, New Zealand). Measurements of both temperature and relative humidity were continually recorded at one second intervals for the duration of each test and then downloaded into Microsoft Excel™. Oxygen was delivered at 30L/min (FiO₂ 0.3), 40L/min (FiO₂ 0.4), and 60L/min (FiO₂ 0.6) flows. After a one-minute baseline measurement period, humidification was ceased for five minutes. On recommencement of humidification, data collection continued until the humidifier returned to its pre-programmed baseline temperature. Absolute humidity was derived from relative humidity and temperature. A linear regression model determined the difference in means.

Results: Baseline absolute humidity was 40.4 mg/L (SD 0.1), 41.2 mg/L (SD 0.1) & 41.8 mg/L (SD 0.1) at 30L, 40L & 60L respectively. Five minutes after ceasing humidification, absolute humidity decreased to 21.3 mg/L (SD 0. 7), 21.7 mg/L (SD 0.1) and 18.7 mg/L (SD 0.1) at 30L, 40L and 60L respectively. Resulting decreases in absolute humidity were 19.1 mg/L (p<0.001), 19.5 mg/L (p<0.001) and 23.2 mg/L (p<0.001) at 30L, 40L and 60L respectively. Baseline absolute humidity was restored after 15 minutes for flows of 30L and 40L but failed to return to baseline after 30 minutes at 60L.

Conclusions: Absolute humidity drops quickly upon ceasing humidification, increasing the likelihood of ciliary dysfunction. When delivering high-flow oxygen during patient transfers, clinicians should be mindful of the consequences of a lack of humidification.  There are some commercially available devices which, through an internal battery, allow the continuous delivery of humidified HFOT. Application of such technology in the emergency department may be beneficial to patients who have a high likelihood of transfer within the hospital.

Background: The concept of magnetic intubation is not new. The idea has been published sparsely, but favorably with limited follow through in the emergency medicine, anesthesia, critical care and surgery literature from Eurasia to America dating back to the 20th century. The current state of airway management in emergency medicine has no clinical application of magnetic field management. The purpose of this Innovation is to provide the emergency physician an additional dimension of magnetic field management seamlessly integrated with their current difficult airway algorithm. Inability to control the coude tip of the bougie as an adjunct tool for the difficult airway commits the emergency physician to surgical airway. 

Methods: The following material were obtained: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Cook Medical Heavy Double Flexible Tipped Guide Wire 60cm, Medtronic Magnet Model 174105, Glidescope LoPro S4, standard trauma shears, and a standard airway mannequin. Shears were used to cut bougie at the 55 mark.  The guide wire was fully inserted. Anatomy was visualized. The magnetic field was applied to the distal bougie in the mannequin oropharynx and hypopharynx with the navigating magnet. 

Results: Magnetic navigation of the bougie coude tip was obtained in the oropharynx. Mechanical and magnetic constraints prevented navigation of the bougie coude tip within the critical hypopharynx. 

Conclusion: Despite the inability to control the bougie tip in hypopharynx due to experienced constraints, the author believes there is potential to optimize the properties of the cannulated wire and the navigating magnet with this innovative utilization of a modified bougie as an integrated conduit to magnetic field management in the difficult airway. This innovation concept could mitigate challenges previously encountered in the study of magnetic intubation.

Introduction:
Paediatric traumatic brain injury is estimated to affect more than 3 million children globally every year, with between 80-90% of cases being classified as mild. The majority of children assessed in Emergency Departments (EDs) are discharged without investigation or treatment and this presents an opportunity for attendance avoidance strategies. Our overall aim therefore, is to derive and validate a decision aid that could be used by parents in the community to safely advise them whether to seek emergency assessment.

Systematic review:

We conducted a systematic review of the existing literature using variations of the free-text terms 'parent', 'head injury' and 'clinical decision rule' along with appropriate subject headings for each term. MEDLINE and EMBASE were searched but neither identified any studies with existing clinical decision rules (CDRs) created or adapted for parental use. The search did identify several validated CDRs for clinician use and of these, the most adaptable for use by non-medically trained individuals was the Paediatric Emergency Care Applied Research Network (PECARN) rule.

Aim of this study:
We will assess the feasibility of parental use of a decision aid by evaluating the inter-rater reliability between parents and clinicians when assessing children over 2 years of age using the PECARN criteria.

Plan of investigation:

(a) Design and setting

This prospective, observational study will recruit children over 2 years of age attending the Royal Manchester Children’s Hospital with a minor head injury. Recruitment is expected to commence from April 2018, with results available for dissemination from August 2018. Parents will be asked to provide written informed consent for the study and children over the age of 10 will be encouraged to assent. The study will be approved by the Research Ethics Committee.

(b) Sampling

Children will be recruited 7 days a week, at any time of day over a 2 month period. Only children who are alert on arrival and that do not require immediate resuscitation will be included. Children who are unable to verbally communicate or are not accompanied by a person with parental responsibility will be excluded. A sample of 45 participants will provide sufficient statistical power to identify a kappa of 0.8 with lower bound of the 95% confidence interval no lower than 0.6.

(c) Data collection

Parents will be given a questionnaire to complete whilst awaiting assessment. The questionnaire contains the PECARN criteria in plain English language, the wording of which has been refined through consultation with patients. The child will be assessed and managed as normal. Afterwards, the clinician will also complete a questionnaire containing the PECARN criteria, blinded to the parental assessment.

(d) Analysis

We will calculate the inter-observer reliability for each individual variable and for the overall rule outcome by calculation of kappa scores and 95% confidence intervals. In accordance with existing literature, a kappa score of >0.6 will be deemed to represent good inter-observer reliability and will be considered sufficient to demonstrate the feasibility of further evaluation through larger studies.

Introduction

There has been much discussion and controversy in the UK about the “weekend” effect as patients presenting to hospital during the weekend are more likely to have adverse outcomes than those presenting during working hours. 

The aims of our study were to identify characteristics of ED attendances and admissions according to whether the arrival time was in or out of hours and to identify whether any differences are due to case mix, acuity or other factors.

Methods

Hospital Episode Statistics (HES) data for ED attendances across 18 EDs in Yorkshire and Humber from April 2011-March 2014 were retrospectively analysed. The entire patient pathway was described by linking patient records in HES A&E data and HES Admitted Patient Care data.

Time of arrival in ED could be described as in and out of hours which was further classified into four categories: ‘weekday day time’, ‘weekend day time’, ‘weekday night time’ and ‘weekend night time’.  In hours was classified as weekday day time; the rest were out of hours.

Comparative analyses were conducted between week and weekend for both day and night; including t-tests, chi squared test, Man Whitney U tests. Linear regression and logistic regression were used to model outcomes by time of presentation adjusting for age, sex, IMD, HRG code and arrival mode. 

Results

Patients presenting to the ED out of hours waited longer to see a clinician and spent a significantly longer total time in the ED, particularly those attending at night time. If a patient arrived on a weekend day, they would be expected to wait an extra 7.74 minutes, on a week night an extra 20.52 minutes, and on a weekend night an extra 21.61 minutes before being seen compared to a week day. Patients are also significantly more likely to not wait to be seen and to subsequently re-attend if they presented to the ED out of hours. This again, was more apparent for those presenting at night time.

Patients presenting out of hours were more likely to be non-urgent (first attendance, no investigations, treatments or referral that required type 1 ED facilities). Patients are significantly more likely to present with non-urgent conditions on weekend 2.6% more, week nights, 15.1% more and weekend nights, 21.3% more.

Patients who attend ED during the weekend day are less likely (3.5%) to be admitted compared to the week day. However, if a patient presents on a week night (13.6%) or a weekend night (11.0%) they are significantly more likely to be admitted. Night time patients were more likely to be admitted but the admissions were more likely to be short stay (potentially avoidable). 

Discussion and conclusions

The results suggest that there is an “overnight effect” rather than a “weekend effect”. Patients presenting overnight have a lower acuity than those presenting in the daytime.  Overnight patients are more likely to be non-urgent, wait longer to be seen and spend longer in the ED.  Overnight patients are also more likely be admitted but for shorter periods (potentially avoidable admissions).

Introduction:
Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. There are few data on the incidence, clinical features and management of patients with acute anaphylaxis caused by analgesic agents presenting to emergency department (ED). 

Objective: To describe the epidemiology, clinical features, management and outcome of patients with analgesic agent anaphylaxis.

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

Results: Inclusion of 694 patients presented in the ED with the diagnostic of anaphylaxis. Analgesic agents anaphylaxis was found in 135 (19.5%) patients. Mean age = 40±15 years. Sex-ratio=0.63. A history of anaphylaxis was reported in 70 % of cases. The most incriminated analgesic agents were:  non steroidien anti-inflammatory agents (58.5%) and paracetamol (27.8).The median time to consult the ED was 314 minutes, with extremes ranging from 5 minutes to 18 hours. Cutaneous features were present in 93% of patients. Cardiovascular, respiratory, gastrointestinal and neurologic features were found respectively in 25, 22, 19 and 2%.  An anaphylactic shock was recorded in 3 patients (2%). Adrenaline was used in 17% of patients intravenously.  Fluid resuscitation was given to 90% of the patients. Two thirds of patients received histamine H1 antagonist, 98% corticosteroids. All of the patients were discharged directly from ED after a mean period of observation as 4 hours. Recurrent reactions were reported in two patients. There was no death cases registered. Patients were all referred to the allergy clinic.

Conclusion: The diagnosis of analgesic agents is missed in emergency services, and adrenaline is underused. Nonsteroidal anti-inflammatory drugs were implicated in many cases of anaphylaxis induced by analgesic agents and suggest the necessity of a standardized guideline for anaphylaxis management in ED.

Importance: Better knowledge of the most painful procedures in Emergency Departments could improve pre-emptive pain management.

Objective: To determine the mean number of procedural painful episodes per patient, and to retrieve information regarding diagnosis, therapeutic procedures and analgesic management, in patients visiting French emergency departments (EDs) for a minor trauma.

Design and Setting: This observational, non-interventional, cross-sectional, multicenter study in adult patients was performed in 35 French EDs.

Participants: All adult patients entering the EDs for a minor trauma on a specified day between 10am and noon were registered, and those consenting were included in the study. A total of 909 patients were registered, 422 were included in the study, and complete data for 409 patients were available for analysis.

Main Outcome and Measures: Pain intensity was assessed using a verbal Numerical Rating Scale from 0 (no pain) to 10 (worst possible pain). An episode was described as painful if the difference in pain intensity between pain just before the procedure and maximal pain during the procedure was ≥ 2. Data were recorded on 1 day in each center by 2 independent nurses.

Results: A total of 409 patients were analyzed, with 1899 procedures. The mean number of painful episodes per patient was 1.0 ± 1.3. 51% of patients reported at least one painful procedure episode. 21% of procedures were considered painful. Clinical examination was the procedure most often reported as painful. No preventive or curative analgesic treatment was reported in 95.1% of procedures.

Conclusions and Relevance: There is a major need for improvement in routine pain assessment and, therefore, procedural pain management for patients in ED. Specific protocols should be developed for procedural pain management, and teams should be trained especially for procedures usually not considered painful.

Introduction

Chin laceration of pediatric patients in the emergency room have been very common in. Because of the tension of chin, the suture should be necessary at the initial stage, but scarring by suture would be broaded if it was kept for a long time. The purpose of this study was to evaluate the effectiveness of early suture removal and using subsequent treatments such as skin bond comparing with conventional method.

Methods

Chin laceration patients under 13 years of age were included in this study. The period was from January 1, 2017 to October 30, 2017, and the wound was limited to simple lacerations without fractures. It also excluded cases with past history of diabetes and malignant tumors, and parents with keloid skin. The patients were divided into two groups; conventional and early group. In both groups, the patients were initially treated by an emergency department for irrigation, subcutaneous and skin suturing of the wounds. Antibiotics were prescribed for dirty wounded cases. In Conventional group, follow up was done at 2nd day to evaluagte and change the dressing material  the wound and the suture was removed on the fourth day. Early group were also followed up on the 2nd day, and suture was removed at that time. After that, tissue adhesive (Histoacryl^®) was applied. Both groups were revisited after 4 weeks, and investigated side effects such as widening, inflammation, length and width of scar, and suture insertion characteristics. Analysis was carried out through R and p value <0.05 was considered significant.

Results

The total number of patients was 131 (Conventional 85, Early 101). The mean age was 8.7 years and 87 male. The cause of the injury was the most frequent cause of falls (72 patients), bumps (35 patients), piercing (12 patients), and others (12 patients). There were significant differences in complications between 6 in Conventional and 1 in Early (p <0.05). however, there was no statistical significance (p = 0.211) in 3 Conventional and 1 early of redness or discharge. The average length of the scar was 17.6mm in Conventional and 15.9mm in Early, but there was no statistical significance. However, the width was narrowed in early group as 1.9mm in Conventional and 1.1mm in Early (p <0.05). The number of scars at the suture insertion site was as low as 75% in Conventional and 42% in Early (p <0.05). The mean diameter of insertion site for suturing was 1.2 mm in Conventional and 0.9 mm in Early (p = 0.138).

Conclusion

Early stitch out and tissue adhesive treatment of pediatric chin laceration patients who visited the emergency department could reduce the scar area and reduce the scar of the suture insert.

BACKGROUND:, Discitis is a rare pathology, potentially serious, and with the possibility of serious sequelae. For these reasons, we have analysed the patients diagnosed in our service to identify and correct possible failures.

METHODOLOGY: Descriptive-retrospective study of patients with suspected diagnosis of discitis in the last 10 years who came to our emergency department 

Variables analysed: age, sex, personal history, clinical symptoms presented, pain characteristics, readmissions, complementary tests requested, hospitalization, time of hospital stay, isolated germ, indicated antimicrobial treatment, surgical treatment used, complications presented, destination of the patient, length of follow-up in consultation ,. Statistical programs: inferences established by chi square

RESULTS: total patients diagnosed with discitis 2008-17: 20. Average age: 68 years (30-89). Men: 57%, women: 43%. With personal history (68%). They presented chronic pain more than 3 months: 67%. , with pain of inflammatory characteristics 31%, fever 2% and neurological focality in 15% of patients. High PCR 50% Transferred from another hospital 35%

MRI was performed: 100% CT 15% affected neck cervical 15% (C5C6: 60%), dorsal: 30% (T11T12: 20%) and numbed area 55% (L4L5: 40%) They presented as complications septic shock: 10 % who required admission to the intensive care unit, one of the patients died; epidural abscess 30% that precise surgical treatment

Hospital admission in 100% of patients with an average stay of 40 days (7-100)

20% of patients returned to the Hospital.

It was biopsied: 85% with 100% culture, being negative in 20% of cases. 85% of the cases required surgery (arthrodesis 5% ,laminectomy 30% instrumentation 5% disectomy 5%

Germs isolated were staphylococcus (16% aureus, 5% epi, 5%, 5% sanguinis, 5%) pseudomonas aeruginosa: 5%

Propionibacterium acnes 16%, mycobacterium bovis 5%, epidermidis MS 5%, enterobacter cloacae: 5% escherichia coli 11%

Antibiotic treatment was used according to antibiogram and it was required a combinations of 2 antibiotics in 95% of the cases (rifampicin, cloxacillin, penicillins, levofloxacin, penicillins, ciprofloxacin, cefazolin, isoniazid, ethambutol for a mean of 4 months (min 2 max 24 ( only in one case due to recurrent infections presented by antibiotic side effects in 2% of patients

Attendance to the neurosurgery department  91% and the 77% of the cases to the infectious service with an average follow-up of 13 months (min 4-maximum 52)

Destinations were: Definitive discharge after follow-up of external consultations in 75% of the cases, referral to the pain clinic: 5%, exitus: 5%

DISCUSION AND CONCLUSIONS:

-The treatment of spondylodiscitis requires multidisciplinary teams and personnel with extensive experience in surgical and infectious pathology.

- High frequency of complications in this pathology, mainly epidural abscesses in the 30% of cases

-Low incidence in our study of post-surgical spondylodiscitis (20%)

INTRODUCTION:

The demand for care at hospital emergency departments has been increasing recently which results in the overcrowding of patients, the delay in medical care for critically ill patients, the excessive costs of health resources, etc. It is important thus to be aware of the characteristics of the care of patients who come to the emergency services based on their origin to establish strategies to promote the appropriate use of these hospital services.

OBJECTIVES:
Analyze the care (priority, request for complementary tests and destination) of patients who come to a Spanish hospital emergency service (HUS) according to their origin

MATERIAL AND METHODS:

An observational, descriptive and retrospective study was conducted by the Emergency Department of the University Hospital of La Ribera (HULR) (Alzira-Valencia) during the period between January 1, 2015 and December 31, 2016

“La Ribera” University Hospital is the referral hospital of La Ribera Health Department. It is located in Eastern Spain and it covers a population of 246440 inhabitants (population census as of December 31^st 2016).

The population under study included patients older than 14 years of age. Pediatric patients, obstetrics and gynecology emergencies were excluded.

The variables studied were: patient's origin (voluntary H), referred from primary care (PH) or voluntary after having been attended to in the emergency room in primary care and having been discharged to the home in the previous 24 hours (PDH), level of urgency, destination to discharge, request for laboratory tests and radiodiagnosis

The analysis of clinical information was  carried out through the program Microsoft Office Access and the data were analyzed at a general level and disaggregated by origin.

RESULTS:

This study took into consideration 223.282 emergency care episodes, all of them related to patients attending to the Emergency Department of HULR.

82.56 % of the patients attended voluntarily, 11.30% were referred from primary care and 6.14% went voluntarily after having received emergency care in primary care and having been discharged home in the previous 24 hours.

The emergency levels assigned in triage to these patients were respectively for H, PDH and PH: P1 (0,07%, 0,14%, 0,15%), P2 (5%, 5,15%, 6,75%), P3 (14,83%, 19,23%, 25,34%), P4 (75,49%, 73,47%, 66,69%), P5 (3,38%, 1,38% and 0,41%).

The percentage of income was 12,29% for H, 15,49% for PDH and 21,31% for PH.

Applications for laboratory tests were 36,16% for H, 49,45% for PDH and 58,40% for PH

Applications for radiology tests were 37,93% for H, 44,24% for PDH and 59% for PH.

CONCLUSIONES:

Differences were observed when studying the characteristics of patient care according to their origin

Patients referred from primary care are assigned a more urgent level of priority and involve a greater expenditure of resources since they are requested a greater number of complementary laboratory and radiology tests

Background: A broad variety of topical hemostatic agents are used in the surgical disciplines. We analyzed the most widely used topical hemostatic agents and compared them to a recently developed, synthetic topical hemostatic agent based on poly lactic acid/chitosan (PLA+C). The materials were compared using a novel testing method based on a rat tail-tip model. Tests were also performed with poly lactic acid/chitosan (PLA/C) that was enriched with the bioactive nanoparticles of curcumin to evaluate if this could increase its hemostatic efficacy.

Methods: The following topical hemostatic agents were compared using a rat tail tip model: chitosan, PLA, PLA/C, PLA/C+ curcumin, gauze. A group with bleeding was considered without dressing intervention. (No material group)

The tail tip was fixated on a developed test device to ensure a constant and equal pressure of the test material on the wound. The mean bleeding time was determined and compared between the groups.

Results: No material group showed a mean bleeding time of 56.2±5.2 min. Mean bleeding time in gauze, chitosan, PLA and PLA/C was 33.8±3.6, 28.5±5.7, 23.4±6.1 and 19.7±3.2 min respectively. PLA/C bleeding time was significantly shorter than other groups. The addition of curcumin to PLA/C did lead to the shortest mean bleeding time (18.1±3.6 min) but this was not significantly faster than PLA/C without curcumin.

Discussion & Conclusions: These results show that PLA/C is a promising alternative for the most widely used topical hemostatic agents. Future studies will have to show if the addition of bioactive nanoparticles like curcumin can significantly improve the hemostatic efficacy of PLA/C.

Introduction. Acute isolated wrist trauma can account for up to 40% of trauma consultations. Wrist trauma results in immobilization and work stoppage, the durations of which vary widely and are not the subject of recommendations. Goal. The main objective of this study is to evaluate the effect of the initial immobilization duration of less than or more than 15 days on the resumption of normal activity in the short term. Method. This is a prospective monocentric observational epidemiological study. Any patient who consulted for a "sprained wrist" was included in the study. Patients are recalled two months after their visit to the emergency room. The primary outcome measure was the delay in resuming a normal and / or occupational personal activity based on the immobilization time prescribed at discharge from the emergency department (less than or greater than 15 days). The secondary endpoint was the duration of the time off work. Results. Over the study period, 196 patients consulted for wrist trauma including 21.4% (42/196) for a sprained wrist. At two months, 76.2% (32/42) estimated that they had a resumption of their normal professional and personal activity. The duration of immobilization greater or less than 15 days did not significantly influence the resumption of normal activity (respectively 28/34 (82.3%) vs 4/8 (50.0%), p = 0.205) nor the duration of work stoppage (respectively 16.73 days (+/- 11.77) vs 10.51 (+/- 2.32), p = 0.06). Conclusion. A short or long wrist immobilization time does not affect the time before a normal activity resumes or the duration of work stoppage. A short-term immobilization could be proposed initially, with a reassessment by a specialist at the end of this period.

Objectives:
The main objective of this study is to measure the degree of patient safety culture among health professionals who work in the emergency department  Hospital. Evaluate the presence of positive and negative factors related to patient safety.

Material and methods:

This is a cross-sectional study that was conducted based on the implementation of the survey "Hospital Survey on Patient Safety Culture," with its version adapted by the Research Group on Quality Management at the University of Murcia.
This survey was distributed and an anonymous self-report of 50 health professionals. The same that included both health and administrative staff, who were working in the emergency department Hospital including dates to 2017.

Results: 

The overall perception of safety was 44%. 68% of the people who take the survey, gave patient safety a score from 6 to 8.  20% of respondents have taken any notice in the last year.Emphasize positive character dimensions "Teamwork within units" with 75%. How weaknesses include “Provision of human resources” with 68% and “Management Support for Patient Safety” with 56%.

Conclusions: 

The low overall level of safety awareness serves as an indicator of the need to increase institutional actions based on patient safety which can encourage a more satisfactory patient care and safe for both parties.
It has managed to identify as a positive factor perception eminently proper teamwork within the unit, a feature that should be promoted and considered within the continuous improvement aspects of the hospital.
The fact of finding as weakness Human Resource Endowment is what generates work overload and in time will increase the margin of error that is exposed to health personnel. We must encourage those responsible for the organization to prioritize adequate hospital rationalization of staff and improvement in working patterns to which they are subjected.Being able to identify the strengths and weaknesses in the security climate in the unit may serve to develop strategies for continuous improvement in

Anaphylaxis: Study of Epidemiological and Therapeutic Characteristics Introduction Certain studies dealing with anaphylaxis from emergency departments suggest that it remains misdiagnosed and under-treated, with behaviors often diverging from international recommendations.

Objectives

To study the epidemiologic, therapeutic and evolutionary characteristics of patients admitted to ED for anaphylaxis. Methods    : Prospective, observational study including patients over the age of 14 who visited a single emergency  and toxicological  intensiv care department between 2007 and 2016 for anaphylaxis. Collection of epidemiological, clinical and therapeutic parameters.

Results:  Inclusion of 105  patients. Average age = 42.52 ± 17.42 years. Sex ratio = (1.29)  . History of anaphylaxis: 80 %(n=84). Clinical signs n (%): cutaneous manifestations 80% (n =85) cardiovascular signs 37 (35), respiratory signs 38% (40), digestive signs 15 % (n=16) and neurological signs 13% (n=14). Allergens incriminated: medicated 58 %, food 14 % and bites of Hymenoptera 28 %.  Anaphylactic   shock state noted in 35 patients   (35%)  Adrenaline was used in 40 % of cases by by direct intravenous injection in 31% of cases   . Corticosteroids and antihistamines were prescribed respectively in 88 % and 80 % of patients. Three patients had recurrences. Two patients had cardiac arrest and one  death was recorded.                                                                              Conclusion:  The prevalence of anaphylaxis in our study was low. This shows that this is a situation that remains so far underestimated. It is therefore imperative to conduct prospective multicentre studies in emergency departments to better determine its incidence and risk factors.

      Upper respiratory tract infection is once of common disses in public health. Some of physician said its self-diagnosis and self-management but some of its type need to see by doctor if its bacterial origin to take antibiotics. The main cause of URTI is viral or bacterial. The viral one is common and self-limited in management. The bacteria one is more complicated than the viral and it is need antibiotics for management. Most of health providers give antibiotic to manage URTI cases to safe their patient or their self as defensive medicine from the URTI complications. The viral cause of URTI is the most cause in community. The antibiotic abused in URTI has harmful effect on patient some time also cost exhausted. Anyhow like any health care institute in the world we have to many prescriptions of antibiotics in URTI some of it are unnecessary. So we have like antibiotics abuse in URTI and it is one of most health care problem in the world.  Actually, the antibiotics may be has harmful effect on the patient like allergic reaction or anaphylaxis. Also may cause cost exhaustion to the patient and government.  For community it induce bacterial resistance also.  This is quality improvement project QIP in origin to reduce unnecessary antibiotics in URTI in our ED but there are some meting points between quality improvement and research. We have good result and improvement after applied our project so we mad it as cross sectional retrospective study.  Our quality improvement project depend on educate our physician about centor score, IDS and AFFP guidelines for URTI management also we made flow chart to how to manage URTI on light of the guidelines.  We found decrees in antibiotic prescription in URTI about 25 % . Methodology : This is cross-sectional retrospective study, to evaluate the antibiotic prescribing pattern in upper respiratory tract infections; before and after the application of the Centor score criteria, IDS and the American Academy of Family Physicians guidelines. Based on the Centor score, IDS and the AAFP guidelines, we developed an algorithm for URTI management. The educational program was started April 1^st 2017 and ended May 1^st 2017. We retrospectively evaluated the use of antibiotics in URTI before and after the educational program. To evaluate the antibiotic prescribing before our program, we randomly selected January 1^st 2017 and to evaluate the antibiotic prescribing after our program, we randomly selected May 10^th2017. Result :We found decrees in antibiotic prescription in URTI about   25 %  . The conclusion :    The education, orientation and guidelines update are very important to prevent any antibiotic abuse or unnecessary .The doctors who write the antibiotic in URTI should be mention why he prescribed it. The URTI management flowchart has to take chance .  

Antibiotics prescription in in the emergencies department at a tertiary moroccan hospital.

The use of antibiotics has revolutionized the prognosis of infectious bacterial diseases. Their role has been decisive in the decrease of their frequency.

However,their inappropriate use continues to emerge of resistance.To better undersand the antibiotic prescribed in emergencies department at a Moroccan tertiary hospital,we proceeded to prospective study form of survey on 400 prescriptions for 3 months from 1^st September to 1^st December 2016.

This study showed that the majority of antibiotics were prescribed in oto-rhino-laryngological infections 38%,wounds and burns 19.5% and respiratory infections 19% .The bet-lactams were the most prescribed molecules 69.5% with predominance of penicillin A + beta lactamase inhibitor and penicillin A and M. Monotherapy was the rule with 97.75%.

The prescription of antibiotic therapy was not justified and non compliant to recommandations in the context of superficial wounds and burns without any infectious risk factor, digestive,upper and lower respiratory infections with viral origin. This can have an impact of the emergence of bacterial resistance phenomena.

The doctor must have a simple and reproductible diagnostic tool to establish the diagnosis,hence the diagnostic interest of biological markers including Creactive protein ,procalcitonin.

The use of referrals in antibiotics ,the reinforcement of the continous training of physicians in infectious diseases and the optimization of the management of the patients in need of treatment must take it possible to improve the quality of the antibiotherapies.

Antibiotics prescription in in the emergencies department at a tertiary moroccan hospital.

The use of antibiotics has revolutionized the prognosis of infectious bacterial diseases. Their role has been decisive in the decrease of their frequency.

However,their inappropriate use continues to emerge of resistance.To better undersand the antibiotic prescribed in emergencies department at a Moroccan tertiary hospital,we proceeded to prospective study form of survey on 400 prescriptions for 3 months from 1^st September to 1^st December 2016.

This study showed that the majority of antibiotics were prescribed in oto-rhino-laryngological infections 38%,wounds and burns 19.5% and respiratory infections 19% .The bet-lactams were the most prescribed molecules 69.5% with predominance of penicillin A + beta lactamase inhibitor and penicillin A and M. Monotherapy was the rule with 97.75%.

The prescription of antibiotic therapy was not justified and non compliant to recommandations in the context of superficial wounds and burns without any infectious risk factor, digestive,upper and lower respiratory infections with viral origin. This can have an impact of the emergence of bacterial resistance phenomena.

The doctor must have a simple and reproductible diagnostic tool to establish the diagnosis,hence the diagnostic interest of biological markers including Creactive protein ,procalcitonin.

The use of referrals in antibiotics ,the reinforcement of the continous training of physicians in infectious diseases and the optimization of the management of the patients in need of treatment must take it possible to improve the quality of the antibiotherapies.

Introduction:

The Register of Advanced Vital Wills (AVW) of Andalusia is created under the law 41/2002 of November 14, basic regulatory of the autonomy of the patient. It is about the written expression made by a capable person, consciously and freely, expresses the options and instructions in sanitary matters that must be respected in the event that there are clinical circumstances in which he can not express his will personally.

The registration of this document is performed in most cases among people with some type of chronic or degenerative pathology, but currently we believe in its usefulness for serious cases treated in the Emergency Department.

Objective:

The objective of our study is the systematic review of all the Trauma Code that occurred in our HED in the last 6 months to determine how many of them had a AVW registry.

Material or patients and method:

A quantitative analysis of the Trauma Code activated in our HED was performed, analyzing the following variables: age, sex, cause of the trauma, severity depending on whether or not they required admission to the Intensive Care and the existence of a AVW registry.

Results:

The total number of patients studied was 25, of which:

- 20% were women and 80% men, with an average age of 41.2 years.

- 32% of the cases required admission to the ICU, of which 8% died.

- Regarding the triggering cause, 42% were due to traffic accidents, 33% to falls, 8% to accidents and the remaining 17% to other causes (hanging, drowning ...)

- 100% of the patients did not have AVW registration.

Conclusion:

The AVW registry can be understood as a consequence of the development of the principle of autonomy. It is a complex process and primary care has an important role to develop, mainly advising and helping to carry out the document.

The usefulness of this document in chronic patients is unquestionable, but we firmly believe that the time has come to make a qualitative leap in its usefulness, bearing in mind that Serious Traumatism is one of the main causes of death and disability, especially in under 35 years old.

When a serious trauma occurs, it causes a stressful situation in the families due to the unexpectedness of the picture that incapacitates the decision making process. In the worst cases it ends with brain death placing the family that has just received the news of the death of their loved one in the position of taking an altruistic position to help a third party with organ donation or in cases that cause a situation of coma not reversible the need to make decisions about whether your family member would want to "live" permanently attached to a respirator.

This is why we believe in the need to disseminate the existence of this document as well as its applicability to any situation without the need to suffer a chronic illness, allowing them to fully exercise their right to autonomy and freeing their family members of this burden.

-Introduction:

The exacerbations of COPD represent nowadays the main reason for consultation in the emergency room of these patients. According to the guidelines in the moderate intensification should be two or more criteria (increase in dyspnea, increase in the volume of sputum, pus-like sputum) for the prescription of antibiotics as part of treatment, while the presence of purulent sputum indicates the use of antibiotics already independently. The use of antibiotics and the choice of one type or another has a precise indication but no longer be in dispute.

-Objectives:   

Rating the use which is made of antibiotics in patients with worsening of COPD of infectious origin according to the Anthonisen´s criterions.

-Material and methods:    

Study observational, retrospective in an emergency department with an area of 200,000 and 275 emergency half a day. We reviewed the medical histories of patients with a diagnosis of COPD who were consulted by intensification of July 2017 to December 2017.

-Results:

Included a total of 139 with exacerbated COPD. 32.4% of the total subjects did not meet the Anthonisen criteria, 27.2% fulfilled a criterion and 36% were two or more.

In general, ranging from antibiotics used, 2.2% took with amoxicillin-clavulanic acid, 18% moxifloxacin, 29.5% with levofloxacin, 0.7% with Cefditoren, 10.1% with ceftriaxone, a 4.3% with Cefalopsporina anti-Pseudomonas 4.3% and other antibiotic 10.1%, while 25.2% were drug-free to home.

For patients who fulfilled these criteria Anthonisen, they went with antibiotic therapy at discharge a % 59,71. In opposition to this fact, 0.7% of patients took prescribed antibiotic at discharge when the criteria were not fullfilled. From the first group of patients, 2.2% took amoxicillin-clavulanic acid, 18.8% Moxifloxacin in 28.67% levofloxacin, 0.7% Cefditoren, a 10.29% ceftriaxone, 4.41% Cefalosporina Anti-Pseudomonas and 9.77 percent of other types.

 - Conclusions

More than 50% of patients with an exacrbation of COPD presented criteria for the use of antibiotics. Our results reveal that the use of antibiotics in the emergency service should depend on the presence or not of Anthonisen´s criteria since its prescription exceeds 50% of the cases where its use is justified.

On the other hand, it reflects that he is not prescribed antibiotic treatment to discharge patients where their use would not be indexed.

The most widely used antibiotic in general is levofloxacin, what is consistent with the clinical practice guidelines.

These results should make us reflect on this aspect which can be improved in accordance with recommendations of when we should use antibiotics in exacerbations or not.

Background：

At present, natural disasters and various man-made disasters occur frequently. Emergency medical rescue can minimize the number of casualties. In China, secondary and tertiary hospitals are the core strength of emergency medical rescue. Right now, the model for the comprehensive assessment of emergency medical rescue capabilities in various hospitals in China has not yet been established. At the same time, ArcGIS software has not yet been applied to the comprehensive evaluation of regional emergency medical rescue capabilities. This study will conduct a comprehensive evaluation of Chengdu's emergency medical rescue capabilities through census and provide reference for emergency medical rescue.

Methods:

The first is to establish an evaluation indicators system. We clarify the primary and secondary indicators and empower them using the Delphi. And then we determine the third indicators and census the emergency medical rescue capability of secondary and tertiary hospitals in Chengdu. Calculating the third indicators using Technique for order preference by similarity to ideal solution(TOPSIS). Finally showing the distribution of emergency medical rescue in different areas of Chengdu uses ArcGIS software

Results:

We get the weights of the primary and secondary indicators by Delphi. Totally we received 19 questionnaires with a recovery rate of 100%. Cronbach's alpha coefficient is 0.933. The weights of emergency management capacity, hospital comprehensive capability, material and equipment capability, centralized treatment capacity and health emergency team were 0.3215, 0.19, 0.1462, 0.1524 and 0.19. As for the comprehensive evaluation system of emergency medical rescue capability, the scores of each hospital were range from 0.1295 to 0.5813 in the comprehensive evaluation system. Based on the comprehensive evaluation system and according to ArcGIS, we made a distribution map of the emergency medical rescue capability of hospitals in Chengdu. And the trend of the emergency medical rescue capability: strong in center and weak in outskirt, and the weak areas include the high altitude western regions and some junction areas.

Conclusions:

In summary, the emergency medical rescue capability of secondary and tertiary hospitals in Chengdu is not bad. While there are still some deficiencies such as the lack of materials and equipments, poor centralized treatment capability and lack of trainming and exercises of emergency medical rescue team. Empirical studies show that the emergency medical rescue capability in Chengdu is uneven distributed, especially the capability in the Junction area among some administrative areas is relatively weak.

Background:

Trauma is still a major global health problem. In Belgium there are around 3000 attributed deaths yearly. Despite this there is no standardised care pathway as existing in Inclusive Trauma Systems in many countries around the world. Patients after severe trauma can be transported to every Belgian hospital with an emergency department [ED] regardless the severity of their injuries.

With the current survey we tried to describe the preparedness and approach to traumatic bleeding in Flemish ED (Dutch-speaking part of Belgium).

Methods:

A survey was sent to all Emergency Departments (ED) in Flanders, Belgium. To do so, we repeatedly contacted the 68 ED both by mail and telephone.

The final response rate was 51,4% (n=35). Our survey consisted of questions tackling general information regarding the size of the hospital and the specific availability of products used in bleeding trauma patients within a certain time frame.

To further evaluate local approach we also presented two typical cases (1 child and 1 adult) with traumatic bleeding. Results were processed anonymously.

Results:

Smaller (<450 beds) hospitals were relatively underrepresented in our study population: 45,7% vs. 72,1% in all Flemish hospitals. Medium sized (450-850 beds) and big (>850 beds) hospitals responded respectively in 76,9% and 90%. All of the responding ED had immediate access to Tranexamic acid [TXA].

Problematic availability for 2 units of packed red blood cells [RBC] was however reported in more than half of the ED; for 2 units of fresh frozen plasma [FFP] this number rose to 63%. A minimum of platelets (8 units) was in stock and ready within the set time limits of thirty minutes in just over 60 %. A rapid infusion device was not available within ten minutes in about one-third of all hospitals. A pelvic binder was not readily available in about 17%.

More clinically, 66% of responders still considered colloids as a standard treatment of hypotension after a major abdominal trauma. Although clear indications for hypovolemic shock TXA was only given by just under 70%. Transfusion of RBC and FFP were hesitantly given. Initial ultrasound evaluation was considered by less than half of all responders.

Discussion & Conclusions:

A great variability was seen between the ED regionwide regarding the management of traumatic bleeding. A substantial number of Flemish ED seem to have limited availability of basic blood products and specific resources necessary to manage traumatic bleeding patients.

Although only a survey, our results seem to suggest that the current approach in certain ED, most often those of smaller sized hospitals, is not guided by the most recent evidence. There is a need for further standardization in management of patients with traumatic bleeding and a better regional organization of the overall care provided.

Approach towards management of patechial rash in children and young patients: a retrospective study 

BACKGROUND: 

In paediatric patients with non-blanching rash (petechial) there are local guidelines in place for the management. This retrospective study was related to evaluate whether there has been a consistent approach in the management of all children and young people presenting in the Children’s Hospital with a non-blanching rash. 

METHODS

This was a retrospective case series of 58 patients between June 2015-Jan 2016. The management of patients within the department was evaluated based on “standard”which was Derby Hospitals NHS Foundation Trust, Division of Specialist Services, Guidelines for the management of petechial (non-blanching rash)-Ref no CH CLIN G73. The “source”of the patients was case notes of patients with primary diagnosis code of petechial rash and meningococcal sepsis. “Data”was collected for 4 main subcategories 

• Patients with petechial rash outside SVC distribution 
• Patients with petechial rash in SVC distribution 
• Febrile but well child with petechial rash 
• Febrile but unwell child. 

RESULTS

Out of total 58, there were 38 male and 20 female patients. The age range was 2 months-12years (mean   2.7 years). 

Category (a):A total of 20 patients with petechial rash in SVC distribution.Out of these 8 had bloods, 3 were treated with oral fluids and  the final diagnosis was not documented in 6 patients. It was cough related petechia in 3,viral rash in 4,viral gastroenteritis 3,innocent rash in 1,low platelets in 1, mechanical cause in 1 and meningococcal sepsis in 1 patient. 

Category (b):A total of 27 patients had petechial rash outside SVC distribution. Out of these 23 had bloods, 10 were treated (6 admitted, 4 ambulated), 17 were discharged and the final diagnosis was viral in 12, meningococcoal sepsis in 4, meningococcal disease in 1, haematological condition in 2, HSP in 1, mechanical 1, reaction to immunisation in 1, tonsillitis in 1 and in 4 patients it was not documented.

Category (c): A total of 5 patients were febrile but well with petechial rash. 4 of these were admitted. 1 patient was ambulated (seen by CED Locum) for antibiotics awaiting blood culture results in 48 hours. Thefinal decision was made by A&E Consultants in 3 cases, Locum CED in 1 case, paediatric SpR in 1 case.

Category (d): A total of   6 patients were in this category. As this cohort was managed acutely as inpatient hence it was not the key indicatory of this audit. 

CONCLUSION: 

A vast majority of patients were well managed as per guidelines. The following recommendations were made for service improvement and establishing consistent approach in management of patients with petechial rash. 

a)  The documentation of diagnosis at discharge needs improving.

b)  Afebrile patients with outside SVC distribution rash should have bloods as per guidelines. In this cohort out of 27,we noticed 4 patients hadn’t had the bloods.

c)   There exists variation in the type of investigations requested and this needs harmonisation.

Background: To adequately consider the will of patients on ethical reasoning in emergency situations in a busy Emergency Department (ED) is a very challenging task.

Advance healthcare directives are assumed to assess the patients will regarding further medical treatment.  However, even after thorough assessment of the provided document physicians are often not able to adequately judge how to proceed in time-critical decisions.

In this study we observed whether advance healthcare directives had been completed by patients beforehand and if these documents were sufficient for physicians working in the ED to judge on important issues such as beginning a mechanical ventilation.

Methods: In the surveyed ED physicians fill out a designated form for treatment goals (FTG) for the course of treatment in the hospital in all cases in which ethical questions are assumed to arise soon or have arisen already. Together with the patient physicians are defining treatment goals. If the patient is not in the necessary condition to understand the importance and consequences of certain decisions, relatives or the family physician will be approached for assessing the presumed will of the patient.

The FTG is done under supervision or directly by consultants of the ED.

One question of the FTG is related to whether an advance healthcare directive is available and if the information provided in that document is sufficient to completely assess the ethical reasoning in this particular medical situation.

Another question of the FTG is on why this particular decision is being made and if an advance healthcare directive has been used as a basis for decision making.

In this observational study we were able to conclude whether advance healthcare directives were available and if they were sufficient for deciding on important medical issues such as end-of-life decisions according to the treating emergency physician.

Results: We have observed that only a small percentage of patients arriving to the ED have already completed an advance healthcare directive. Of these patients a substantial number were able to present the document when they entered the ED.

If an advance healthcare directive was available, in most cases the decision for further treatment was not based on the statements provided by the advance healthcare directive only.

Discussion and conclusions: Advance healthcare directives are a useful information source for evaluating the will of the patient. However, it seems that the information provided is not sufficient in most cases presented to the surveyed ED. Therefore, it could be beneficial to include other information in the advance healthcare directive.

Further research is necessary to understand why the provided data of advance healthcare directives are not sufficient for the emergency physician as a source of information for coming to a decision. It could be helpful to adjust the advance healthcare directives to the individual patient´s medical condition and update on a regular basis.

This observational study is still ongoing therefore preliminary results without showing exact numbers are presented in this abstract only.

Backround:

The clinical challenge for evaluating minor head trauma in pediatric patients is to identify those infants and children with clinically important traumatic brain injury (TBI) while limiting unnecessary radiation exposure.In this study, we aimed to investigate the relationship between trauma severity and platelet indices (PI) and white blood cell (WBC) count to identify TBI in children with MHT.

Methods:

This prospective study included children with acute isolated MHTwho underwent head computed tomography (CT) based on Pediatric Emergency Care Research Network (PECARN) criteria. The patients were compared with healthy children (control group).The abbreviated injury score (AIS between 1 and 6; 1 minor injury, 6 unsurvival injury) was calculated. Severe trauma is defined clinically by any of the following is present: admission for at least 48 hours, admission to pediatric intensive care unit, endotracheal intubation, anti-edema treatment, transfusion, and death. Mean platelet volume (MPV), platelet distribution width (PDW), MPV to platelet ratio (MPV/PL), MPV to WBC ratio (MPV/WBC), and MPV to Neutrophil ratio (MPV/Neu) were evaluated. Correlation and ROC curve analysis were done.

Results:

86 children (median age: 3 years; 25-75 percentile: 1-7 years; minimum: 1 month; maximum: 17 years; male/female: 59/27) and 245 controls were included the study. There was not statistical difference between the patients and controls in terms of age and gender (p>0.05). 36 patients had abnormal CT; 21 of them (24.4%) were admitted to the hospital; 5 patients (5.8%) were underwent neurosurgery operation. No patients died. WBC, neutrophil count, MPV, MPV/WBC, MPV/Neu and MPV/PI ratios were statistically different among patients with abnormal CT, patients with normal CT and healthy controls (p<0.05). WBC, neutrophil count, MPV/WBC, MPV/Neu ratios were significantly different between severe and not severe trauma groups, and between AIS < 2 andAIS ≥2 groups (p<0.05). The strongest correlation was found between AIS and neutrophil count (r: 0,365; p<0.05). For predicting AIS > 1, the AUC values of WBC, neutrophil, MPV/WBC and MPV/Neu were 0.746, 0.739, 0.726 and 0.724, respectively.

Discussion & Conclusions: 

In children with MHT who underwent CT, WBC and neutrophil counts, MPV/WBC and MPV/Neu ratios may be helpful for predicting the severity of trauma in pediatric emergency department.

Study Objective: Renal stones can be caused by bacteria (infectious stones) or can be secondarily infected (stones with a UTI), leading to a septic stone/sepsis. The presence of white cells on urinalysis may indicate infection or ureteral inflammation. There is a wide practice pattern of ED physicians and urologists when treating pyuria associated with renal stones, with a lack of data in the literature to show which patients may have an infection. The goal of this study is to describe renal colic patients, confirmed by CT imaging, with culture proven (uCLX) intercurrent infections, based on demographic and lab data at the time of diagnosis. Such analysis could help to risk-stratify patients more accurately for admission/antibiotic treatment.  Methods: We performed a retrospective study looking at vital signs, demographics, UA and urine culture results to determine if patients with infectious stones, or stones with infection, can be identified. Data was extracted from an electronic charting system from a sub-urban medical center with an adult/pediatric visit volume between 90-100k visits. Appropriate statistical test with a significant p of <0.05 were performed. All patients > 21 years of age with an ICD9/10 diagnosis of renal colic with a confirmed CT diagnosis between 1/3/2014 and 4/23/2015 were included. Results: 375 charts were reviewed with 261 having a CT confirmed stone. 150 were men (57.5%). The median age was 53.4 (95% CI 51.2 to 55.4; IQR 43.2 to 62.4). 33 patients (12.6%) had a UTI at > 10,000 CFU. There was a significant difference with regards to a +uCLX vs -uCLX based on gender (females 20/111 vs males 13/150; difference of proportion -0.21; [95%CI -0.39 to 0.03], p<0.04), age (median difference -8.59; [95% CI -14.0 to -3.26]; p<0.002). There was a significant difference in +uCLX based on presence of wbc’s on UA (7/181 [3.8%] for 0 wbc; 5/25 [20%] for 5-10 wbc; 1/12 [8.3%] for 10-20 wbc; 1/14 [7.1%] for 20-50 wbc; 19/29 [65.5%] for >50 wbc; p<0.0001). There was a significant difference in +uCLX based on + vs – nitrites (20/238 [8.4%] for nitrite neg vs 13/23 [56.5%] +uCLX for nitrite pos; diff of proportion 0.35 [95%CI 0.18 to 0.52]; p<0.0001). There was a significant difference in +uCLX based on + vs – bacteria on UA (8/173 [4.6%] no bacteria; 4/42 [9.5%] few; 9/15 [60%] many; 4/19 [25%] moderate; 7/10 [70%] TNTC; p<0.0001). There was a significant difference in admission vs discharge for +uCLX vs –uCLX (21/33 [63.6%] vs 51/228 [22.3%] respectively; p<0.0001). There was no difference in return within 30 days for discharged patients based on + vs -CFU (3/11 [27.3%] vs 20/175 [11.4%]; difference of proportions 0.15, [95%CI -0.11 to 0.43]; p<0.28). Conclusion: There appears to be significant correlation with several clinical and laboratory data that may aid in predicting urinary tract infections associated with kidney stones. Females are more likely to have positive uCLX while there is also correlation between being +uCLX with the number of WBCs; being nitrite positive, and increasing levels of bacteria on the UA.

Introduction

Emergency Medicine (EM) is one of the youngest medical specialities in the United Kingdom. It has risen from the inauspicious days of “Casualty” to take its place as one of the key acute specialities involved in caring for severely ill or injured patients. EM also provides medical input into the Minor Injuries Unit (MIU) caring for people at the opposite end of the acuity spectrum. This friction has sparked extensive debate within the speciality about how to ensure trainees receive adequate training to deal with both ends of the spectrum.

Methods

70 West of Scotland (WoS) EM trainees were surveyed via email inviting them to complete a survey generated using Google Quiz. The survey asked trainees to rate their competence level in various minor injury procedures, their attitudes towards /experience in minor injuries training and also how much clinical time per month they spent working in MIU. The procedures surveyed were derived from the Royal College of Emergency Medicine's 2015 curriculum. 

Results

29 responses were received including trainees from 8 separate hospital sites representing 3 health boards in the WoS. Respondents ranged from ST1 to ST6 level. Trainees generally reported being comfortable with most of the practical procedures listed. They also reported that they enjoyed working in minor injuries and they felt their training was appropriate. A recurring theme in the free comments space, however, were concerns about limited time spent in MIU as the service has become increasingly nurse practitioner led and the impact of this on their ability to deal with more complex presentations. The majority of respondents (n=18) worked 0-3 MIU sessions a month.

Discussion/Conclusion

Emergency Medicine trainees in the West of Scotland enjoy working in MIU and their training appears to equip them to deal with simple presentations. Ensuring they receive adequate training to deal with complex presentations is a concern and should be a key focus of any future curriculum revisions. Potential solutions include protected minor injuries sessions and more novel solutions such as a specific minor injuries training courses, shadowing sessions with physiotherapists and allocated clinical time in speciality clinics (fracture/burns/opthalmology) and theatre lists (trauma/plastics). 

Background. Triage nurse uses a semi-structured scoring system that categorizes the level of clinical urgency of a presenting problem based on inputs from several sources. Notwithstanding, there is no comprehensive study that assessment the physician adherence to the urgency classification.

Aim. To examine whether the physicians at Rambam Health Care Campus adherence to the urgency classification as determined by the Canadian Triage and Acuity Scale (CTAS). CTAS allow Emergency Department (ED) physician to triage patient's according the type and severity of their presenting signs and symptoms and ensure that the sickest patients are seen first.

Method. A retrospective-archive study was conducted at the Rambam Health Care Campus ED in the north of Israel from January 2011 to December 2015 (n=392,687).

We used the CTAS to examine the physician adherence. CTAS is a 5 level (P1-P5) triage scale in which each acuity level indicates the estimated waiting time for a patient seeking emergency care. For each patient, we examined the association between the urgency rating set by the triage nurse and the waiting time for the physician by using univariate and multivariate analysis. A comparison was performed between several sub-groups: season (winter/other), patient arrival time (morning /evening or night shift), area (urgent, emergent, shock room), where the patient was examined, the first consultant that examine the patient (eg., internist, surgeon or orthopedist).

Results.  The distribution of the classification was heterogeneous. 7,133 (n=1.8%) of the patients were classified as P1; P2- 17,318 (n=4.4%); P3- 148,657 (n=37.8%); P4-113,502 (n=28.9%); P5- 106,077 (n=27%). The median and interquartile range for the time from triage until physician assessment, by triage group, were: P1 0.7 minutes (0.2 - 24.3); P2 35.1 (13.1-75.9); P3 43.5 (21.1-88.4); P4 45.3 (19.8-87.3) and P5 46.0 (21.5-87.8). The percent of visits that met the goal of evaluation time, by triage classification, was: P1 61%, P2 27%, P3 37%, P4 61% and P5 85%. No statistical significant results were found regard to the sub-groups. In this comparison, too, the physician's adherence was mainly in the P5 level.  

Conclusion. The standard goals for time to physician are not been met base on the similarities of the duration between P2-4, this is likely because the physicians are not consulting P when deciding whom to evaluate next. System wide change in physician workflow and awareness should be assimilated as early as the work of the teams in the ED.

Introduction

Atrial fibrillation is the most common arrhythmia in clinical practice. About 25% of the world´s population over 40 years age will suffer it across their life. Atrial fibrillation is associated with a high risk of thromboembolic complications, fundamentally stroke. Oral anticoagulants have shown their ability to reduce this risk.

Objectives

To establish whether there is agreement between the anticoagulant therapies prescribed in the emergency department and those prescribed during the first revision after discharge in cardiology consultations.

Patients  & methods

A descriptive, observational and retrospective study in a General Hospital in Murcia (Spain) is described. This hospital manages a population of 200,000 people and 275 emergencies / day. In this study, 240 patients with atrial fibrillation from the 1^stJanuary to the 31^thJune 2017 were included.  The analyzed variables are: average age, sex, anticoagulant treatment prescribed in the emergency room at discharge and scheduled in cardiology consultations. IBM® SPSS version 21.0 was used as statistical program.

Results

The sample under study was constituted by 61.67% women and 38.33% men with an average age of 71 years. Our study is focused in 56.67% of the patients, who was first evaluated in the emergency room and later in the cardiology consultation. 82.35% of these patients were prescribed with anticoagulant therapies in the emergency room: acenocumarol 32.35%, rivaroxaban 30.15%, apixaban 9.56%, dabigatran 6.62%, warfarin 5.15%, heparin 2.94%, endoxaban 0.74%; no therapy receivedby the reminder patients. 29.41% of the anticoagulant therapy prescribed in the emergency room suffered a change after the evaluation in the cardiology consultation. The distribution of oral anticoagulant therapies prescribed at discharge changed as following: acenocoumarol 39.71%, rivaroxaban 21.32%, apixaban 11.76%, dabigatran 7.35%, warfarin 5.15%, endoxaban 1.47% and heparine 0.74%.

Conclusion & perspectives

The majority of patients received anticoagulant therapy at the emergency discharge following the recommendation of the CHA2DS2-VASc and HAS-BLED scales. After the evaluation in cardiology consultations, the anticoagulant therapy suffered approximately 30% of change. Concretely, it was observed an increase in the prescription of acenocoumarol and the new oral anticoagulants, but the prescription of rivaroxaban decreased.

Basic and aims

Sepsis is one of biggest challenge in the Emergencies units and Intensive Care units, where is one of the main causes of death.  It begins unexpected and it spreads quickly. The last definition of sepsis is described as an “organic dysfunction caused by an anomalous host and it’s a threat for the survival”.  In the present study we will analyze the usefulness of blood cultures in cases in the presence of sepsis in the emergency units, trying to correlate them with the antibiotic treatment, the focus of infection and at the same time make a comparative blood culture with other analytical results for the determination of sepsis, such as lactate, procalcitonin, and C-reactive protein.

Methodology

An observational, analytical, descriptive, cross-sectional and retrospective study performed in the emergency department of La Ribera University Hospital. For the collection of data, all clinical records of patients diagnosed with any type of sepsis during the year 2016 were reviewed.

Results

A blood culture positivity of  25.20% was obtained although only 4.20% of the results were available while the patient remained in the emergency department. The most frequent source of infection was Urinary and the most frequent microorganism  was Escherichia coli, being the antibiotic most used and without resistance in the sample Ceftriaxone. Regarding the biomarkers, procalcitonin obtained a statistically significant association with the blood culture.

Conclusions

The Procalcitonina, represents greater diagnostic utility against the blood culture during the stay of the patient affected of any type of sepsis in the emergency department. The 3rd generation cephalosporins proved to be the most sensitive strains against Escherichia coli. Lactate and PCR Biomarkers are most useful in serial samples to monitor the evolution of the patient affected by any type of sepsis in the emergency department

Are we getting better managing and planning for acute deterioration of patients? - A cross-sectional study of arrest calls at the Royal Alexandra Hospital

Background

In 2016 a cross-sectional study of all (69) peri-arrest and arrest calls at Royal Alexandra Hospital (RAH) between August 2016 to  October 2016, found a third of patients had incorrectly recorded or timed observations leading up to a 2222 event, or inappropriate escalation to medical staff.

Following that study nursing education sessions were put in place, the results were shared with the relevant medical teams throughout RAH and the resuscitation report forms were highlighted to registrars and middle grades in order to generate greater compliance. This study looks at whether these measures have improved following the study in 2016.

Method

A cross-sectional study reviewing all peri-arrest and arrest calls put out at RAH between August 2017 and March 2018 involving review of the resuscitation report, as well as nursing and medical documentation prior to and during the 2222 event. In particular NEWS recording and any escalation this should trigger, escalation planning e.g. ceiling of care and DNA CPR form, as well as adherence to the ALS algorithm.

Results

Between 1^st August 2017 and 27^th March 2018 there were 191 arrest or peri-arrest calls logged by switchboard. Of these, 120 (approximately 63%) had completed resuscitation reports, reflecting an increase from the 2016 study. Information was retrieved on a further 38 calls, there was no data available for the remaining 33 calls leaving an available data pool of 158 calls.

From the data available, 35 calls were for cardiac arrest, with 123 for peri-arrest. The key results were that a minority of patients were found to have inappropriate NEWS recording (12%), NEWS timing (5%) and/or inappropriate escalation (7%). Overall 63% of calls had correct NEWS timing, recording and escalation prior to a 2222 call as per local protocol. Only 17% of patients had an escalation plan documented prior to a 2222 call and following peri-arrest 45% had an escalation plan in place, this was a reduction compared to 2016 and may reflect the larger cohort size. Considering the cardiac arrests, 6 of the 35 calls (17%) had incorrect adherence to the advanced life support algorithm relating to either timing or type of medication administered.

Conclusion

These results suggest nursing documentation has improved since the study in 2016. However planning for patient deterioration is much worse and this needs to be a priority for medical staff when reviewing patients as it aids patient centered care and decision making in events such as these. The findings of this study will be shared with medical and nursing staff to generate discussion around documenting escalation planning and responding to deteriorating patients and highlights the importance of ensuring that patients entering the emergency department have appropriate care plans put in place at an early stage.

Extra information

This study formed part of my non-clinical work as a clinical development fellow, did not receive any funding and ethical approval/informed consent was not required.

Background & Aims

The average age of cases reported on the Trauma Audit & Research Network database is increasing with falls from less than 2 meters now the most common mechanism of injury. One common injury associated with a fall in the elderly is a fractured neck of femur (#NOF), which carries an incidence of 75,000/year in the UK alone.  There is limited research looking into the association between #NOFs and the presence of secondary diagnoses. We aimed quantify the incidence of secondary diagnoses (injuries and medical problems) in patients presenting with #NOF, and understand whether current trauma assessment methods for elderly patients with #NOF are sufficiently rigorous to enable to detection of additional diagnoses.

Methods

A retrospective case note review was undertaken at a single Major Trauma Centre (MTC) within the West Midlands region of England. Patients aged ≥65, who had suffered a low fall and had a primary diagnosis of a fractured neck of femur (#NOF), plus an additional emergency department diagnosis code were included. Completeness of clinical documentation was assessed using twelve criteria derived from a bespoke schema for geriatric trauma assessment; the Heartlands Elderly Care Trauma & Ongoing Recovery Course. Each category scored 1 point, with the maximum attainable score being 12.

Results

Patients were identified as those who attended with a primary diagnosis of #NOF between November 2016 and October 2017 (n=530). Of these, 42 also received an additional diagnosis (7.9%). Within this group, there were 33 additional injuries and 17 additional medical diagnoses. The anatomical distribution of injuries were in all body regions: head (20%), torso (38%), and extremities (42%). 

The mean assessment score was 7.69 out of 12 points (range 4-12 points). Full observations were most consistently reported (100%). In contrast other areas scored poorly, these included: airway (21%), C-spine (17%) and glucose recordings (24%). There was also great variation between clinical grade and profession, with Advanced Nurse Practitioners scoring the highest (mean 9.40), and Foundation Doctors performing the worst (mean 6.30).

Discussion

There was an appreciable incidence of secondary diagnoses in this sample of patients. This study reveals inconsistent documentation of trauma assessment for patients who have sustained #NOF in one UK MTC. Although this retrospective case note review is not a direct assessment of quality of care, it could be reflective of deficiencies in care. In addition, high quality documentation is essential for professional communication, governance, and medicolegal reasons. There is a risk that if patients do not receive a comprehensive assessment, secondary injuries could be missed and increased morbidity and mortality result. Patient factors such as cognitive and communication impairments, and clinician factors such as the application of search satisfaction and anchoring heuristics may make this even more likely in elderly patients who present with an obvious primary injury such as #NOF.

This study has identified a need for improved training in ‘silver trauma’ and standardisation of geriatric trauma assessments and documentation. Moving forward interventions such as an elderly trauma proforma and trauma workshops for junior grades has been proposed.

Background: Paracetamol is commonly taken in acute overdose. The overdoses of paracetamol can cause hepatic toxicity and kidney damage. Hence, the determination of paracetamol receives much more attention in biological samples and also in pharmaceutical formulations. Here, we report a rapid and sensitive nanosensor for detection of the paracetamol in blood.

Methods: This Qualitative assay kit was designed to change its color at the three levels of Plasma concentration of acetaminophen as follows: dark red for Serum level above 100mcg/ml (high risk), red for Serum level between 25 -100mcg/ml (intermediate risk) and pink for Serum level below 25mcg/ml (low risk) was contracted.

Acute Acetaminophen over dose, induced in rats by the oral administration of a single dose of 2 g/kg N-acetyl-para-aminophenol (APAP). One hour after administration of acetaminophen toxic dose, the Plasma concentration level of acetaminophen was evaluated by kit. 2 and 5 hours after acetaminophen toxic dose administration, liver enzymes were examined, respectively. The relationship between liver enzymes and serum acetaminophen levels which determined by the kit was investigated.

Results: One hour after the administration of toxic dose, 73 rats, had serum levels above 100mcg/ml (group A), 22 rats, had serum levels between 25-100 mcg/ml (group B) and 5 rats, had serum levels less than 25 mcg/ml (group C). Aspartate transaminase (AST) was measured in group A, B and C, 106.22±1.05, 100.15±0.00 and 108.71±1.01 (IU) respectively, 2 hours after toxic dose administration. The same way, Alanine transaminase (ALT) was measured in group A, B and C, 32.54±0.59, 32.76±0.59 and 32.68±0.54 (IU) respectively. There was no significant difference between the groups.

5 hours after the administration of toxic dose, AST was measured in group A, B and C, 274.49±1.27, 173.17±2.22 and 134.85±2.31 (IU) respectively and also ALT was measured in group A, B and C, 156.5±0.00, 93.91±0.23 and 44.54±0.91 (IU) respectively. There was a significant difference in the level of liver enzymes in the group A, which was reported high risk by nanosensor.

Discussion & Conclusions: This point-of-care test could be used to rule out an overdose with acetaminophen, and could thus lead to earlier clinical decisions for suspected overdose patients.

Introduction : Pain is the main reason for emergency department consultation. The goals of pain management include recognition, treatment adjustment, and systematic and regular reassessment. The analgesia must be early and adapted to the patient.

Methodology and tools: Our prospective descriptive evaluative study based on an anonymous questionnaire developed and self-administered, carried out in the emergency and orthopedic departments of the university hospitals of the region during the month of February 2016.

Result : Our study was conducted with 50 nurses. The sex ratio was 0.51. The majority of respondents (74%) think that the treatment of a pain makes camouflage the etiology of the latter. 90% of nurses report assessing the intensity of pain before it is taken care of. The most commonly used self-assessment scales are : visual analog scale (86%) and simple verbal scale (68%). Only 12% of respondents say they know the definition of multimodal analgesia.

Conclusion : This study has identified gaps in the management of acute pain and identified the causes of oligo-analgesia. The effectiveness of pain management in emergency medicine is based on its recognition, implementation and application of protocols adapted to the pathology and the patient. Multimodal analgesia combines physical, psychological and medicinal means is a way to reduce the adverse effects of analgesic treatments.

Introduction : Transthoracic echocardiographic examination (TTE) that is performed at the patient’s bedside in emergency departments has several recognized important indications. 
Objective: The purpose of our study is to evaluate the agreement of the estimates of left ventricular ejection fraction (LVEF) obtained by emergency physicians with the findings obtained by cardiologists in patients admitted to emergency departments. 
Material and methods: This randomized prospective study was carried out in the emergency department over a period of 6 months, involving patients aged > 16 years whose condition required an emergency TTE. 
The patients included in the study had to undergo a double echocardiographic examination: An initial investigation that was performed in the emergency department by an emergency physician who had previously received a three-month training in Doppler echocardiography. 
A subsequent echocardiographic examination that was performed by an echo-Doppler proficient cardiologist. 
Left ventricular ejection fraction was evaluated by both readers using the following methods: the global visual estimation (GVE) method, Teicholtz’s method in time movement mode (TM) and Simpson Biplan method (SB). 
We excluded from the study patients with segmental kinetic disorders or with hearts out of alignment. The findings thus obtained were compared using the inter-class concordance coefficient of Cronbach’s alpha. 
Results : Fifty-two patients were involved in the study. Mean age was 55 + 11 years; sex-ratio was 7 males/4 females. 
For the GVE method, the findings obtained by the emergency physician were similar to those obtained by the cardiologist: alpha = 0.72 (IC 95% = [0.68-0.78]; p<10-3). 
The findings obtained by both operators by Teicholtz’s method were as follows: alpha = 0.94 (IC 95% = [0.80-0.95]; p<10-3). 
The concordance of the findings obtained by the emergency physician and of those obtained by the cardiologist for their assessment of LVEF by SB method was shown by alpha=0.91 (IC95% = [0.80 – 0.98]; p<10-3). 
Conclusion : Global visual estimation of LVEF can be performed similarly by an emergency physician or by a cardiologist provided they are sufficiently experienced. The results yielded by both other methods (Teicholtz’s method and SB method) were very similar indicating an excellent concordance independently of the degree of deterioration of the left ventricle contractility. Biplan Simpson’s method is, however, a time-consuming procedure. 

Introduction: Current medical education in emergency medicine was based primarily on theoretical education and apprenticeship learning. Life-threatening emergencies had a low incidence, and needed quick management which make them unattractive to teaching. However, studies shown that there was a real deficiency in this area. Medical simulation has been the subject of many studies and could allow this learning.

The objective of this work is to evaluate the benefit of medical simulation for the acquisition of knowledge and practices concerning the management of rapid sequence intubation (RSI) in emergency structure.

Material and methods: We carried out a prospective, randomized, controlled, open-label study from April to August 2017. All the emergency students registered in 2016 were included . The participants were then randomized by random draw into 2 groups: a simulation group (benefited from an initial simulation session, Time 1) and a control group (only benefited from a theoretical recall of knowledge, Time 1). At 3 months (Time 2) the 2 groups participated in a simulation session on the same topic. We also performed multivariate analyzes to take into account any previous participation in simulation sessions and the score at Time 1.

Results: 29 participants (14 in the simulation group and 15 in the control group) were included. The 2 groups were comparable in terms of previous participation in simulations, hospital function or RSI experience. At Time 1, there was no significant difference in the overall score between the simulation group and the control group (respectively, 29.1 ± 1.8 vs. 28.3 ± 2.2). After multivariate analysis, at Time 2, the simulation group had higher results than the control group on the overall score (respectively, 41.0 ± 4.7 vs 37.5 ± 3.5, p = 0.01), on the practical skills (10.5 ± 2.1 vs 8.7 ± 2.1, p = 0.03), on the theoretical skills (30.6 ± 2.9 vs 28.8 ± 2.1, p = 0.03), on the technical (25.9 ± 5.9 vs 18.4 ± 5.7, p = 0.002) or non-technical skills (30.2 ± 4.6 vs 24.9 ± 5.9, p = 0.002) .

Conclusion: Our study showed that medical simulation could be an interesting alternative for the acquisition of knowledge, technical and non-technical skills in the context of an rapid sequence intubation among emergency students.

Introduction.

A National  French report in 2016 confirm a national trend towards increased consultations at the Pediatric Emergency Department. These situations are responsible of overcrowding, longer waiting times and dissatisfaction of medical and paramedical professionals and users. The main purpose of the study was to describe the reasons for using Pediatric Emergency Depratment. The secondary objective was to identify which consultations are primary care.
Methods.

We carried out a descriptive epidemiological study by anonymous survey in our Pediatric Emergency Department from May 31 to June 27, 2017. The patients included were children from 3 months to 16 years old who came to this department of our University Hospital. The primary outcome measure was the consultation rate. The secondary outcome was the prevalence of primary care visits.
Results.

During the study period, 176 answers of the survey could be used. The average age of children was 7,1 years old. The consultations took place in the afternoon for 44.24%, of which one third between 12 and 14 hours. The mother was the main caregiver, 60% of them had a declared professional activity. The reasons of consultations were parents who had judged the state of health of their child worrying (55.7%), the non availability of the doctor of city (22.5%), deadlines of appointments judged too long (14.94%) and easier access to a doctor (8.57%) and to locals (16%). Near one every five patients (18.9%) judged a better quality of care. The consultations in the Pediatric Emergency Department could have been, for half of them, primary care (50.5% simple medical order and 47.52% trauma: p <0.0001). Moreover,  60% of Pediatric Emergency department consultations were considered as primary care at the time of the medical assessment.
Conclusion.

Our study has shown that half of the consultations in our Pediatric Emergency Department were primary care and raised the question of the need for a physician to receive patients in order to regulate the flow by redirecting to outpatient care and thus reduce the time of first medical contact in case of emergency. A study by semi-directive interviews would make it possible to know the specific expectations of the users from the ambulatory care system.

Objective

We studied the effect of a centralization of dispatcher center on dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) program for out-of-hospital cardiac arrest (OHCA).

Methods

All emergency medical services (EMS)-treated adults in the Kyounggi province (34 fire departments covers 43 counties, a population of 12.6 million) with OHCAs of cardiac etiology were enrolled between 2013 and 2016, excluding cases witnessed by EMS providers. In Kyounggi province, 34 agency-based dispatcher centers were unified sequentially into two province-based central dispatch centers (north and south) between November 2013 and May 2016. Exposure was centralization of dispatcher center. Endpoints were BCPR and dispatcher-provided CPR instructions. Generalized linear mixed models for multilevel regression analyses were performed.

Results

A total of 11,616 patients (5,060 for before-centralization and 6,556 for after-centralization) were included in the final analysis. The OHCAs occurred during the before-centralization period were more likely to receive BCPR (44.6%, 16.6% BCPR-with-DA and 28.1% BCPR-without-DA) compared with them during the after-centralization period (62.6%, 50.6% BCPR-with-DA and 12.0% BCPR-without-DA) (p <0.01, adjusted OR: 1.59 (1.38–1.83), adjusted rate difference: 9.1% (5.0–13.2)). For dispatcher-provided CPR instructions, the OHCAs occurred during the before-centralization period had a higher rate than them during the after-centralization period (23.1% vs. 67.4%, p <0.01, adjusted OR: 4.57 (3.26–6.42), adjusted rate difference: 30.3% (26.4–34.2)).

Conclusions

Centralization of dispatcher centers was associated with improved bystander CPR rate and dispatcher-provided CPR instructions for OHCA patients.

Background: The concept of time in the emergency department (ED), and particularly the idea of crowding is a global concern in emergency care. There is no agreed definition of crowding, however it encompasses the idea of working beyond capacity for which a department is designed and resourced to manage a given population. Crowding is tightly related to occupancy and of course flow of the patients. The assumption is that crowding leads to reduction in quality care, delayed in recognition of life threatening illness and therefore poor outcome and possible increased mortality. Delayed loading and poor flow have sadly led to the rise in hospital corridor medicine. There is no doubt that crowding is associated with poor ED performance and delayed adequate care such as time to antibiotics or time to analgesia, however there has been little review of the data regarding mortality. The impact of occupancy and mortality is currently speculative. The true impact of crowding on patient safety is still to be identified and targeted. Several factors such as the definition of crowding, the heterogeneity of the population or even the standard measurements used in various studies are challenges in the review of crowding and its relationship to mortality.

Method: Articles selected were focused on the association between boarding and in-hospital mortality (IHM). Literature search strategies used MeSH and text words related to EDLOS. Search was performed on Medline, Embase, Cochrane Library, Web of Science, CINAHL and PsycNET. The selection of articles was done with F1000 software. Two reviewers independently screened the titles and abstracts yielded by the search to identify relevant abstracts. Full articles with title or abstract meeting the inclusion criteria were retrieved and the reviewers selected those that meet inclusion criteria. Data extraction included study characteristics, prognostic factors, outcomes, and IHM.

Results:3,577 references were screened by the two independent reviewers. 68 papers were selected and of those 14 were specifically selected for their review of crowding and mortality. 

Of the 14 studies, 13 were large retrospectives studies and one was a prospective study. Four of the studies were multi-centered studies with very large population review. All the studies looked at mortality as a primary outcome. The majority of the studies suggested significant increased mortality during crowding periods. Verelst et al, Jiwon et al and Arbabi et al shows that ED crowding was associated with longer hospital stays but not with increased mortality or no difference in outcome or quality of resuscitation. Crowding was associated with delayed resuscitative efforts and increased mortality in the ED and in hospital in general. Supporting this idea other studies studies like Fatovich at all and Crilly et al found that decreasing crowding reduce the mortality rate.

Conclusions: Most of the studies shows that there is a significant relationship between crowding and increase in-hospital mortality rate. Measures should be taken at the hospital level to improve the ED patient flow which could improve negative outcomes.

Background: Venous Thromboembolic Disease (VTD) is a prevalent condition in the Emergency Department of the Hospital and has very different clinical manifestations: Deep Venous Thrombosis (DVT), Pulmonary Embolism and Superficial Venous Thrombosis. Between 15-20% of patients with VTD are patients with cancer. These patients have a high risk of serious complications, including death related to Venous Thromboembolic Disease. In patients with cancer, the location is more frequent in the upper limbs, however, the most common form of DVT presentation is in the lower extremities of the population without cancer. The risk factors to present VTD in the population without cancer are the use of oral contraceptives, cardiovascular risk factors (Hypertension, Diabetes Mellitus, Dyslipidemia), immobilization, surgeries, ...

Our objective is to study if there are differences in the clinical presentation in patients with cancer and without cancer and the risk factors associated with each of the groups.

Materials/methods: It is a prospective study of cases and controls diagnosis. The cases were diagnosed of VTD in the Emergency Department of a tertiary hospital between January 2013 to March 2016. The patients were followed in outpatient consultations during 3 years. The potential risk factors collected were the demographic data, the underlying diseases and clinical characteristics of the episode. Univariate and multivariate analysis were performed using logistic regression.

Result: Our cohort presents 718 patients, of them 132 (18 %) were patients with cancer, 586 (81.6%) were patients without cancer.

In the cohort of patients with cancer, DVT of the upper members was more frequent than in patients without cancer, these differences being significant (85.60% vs 14.40%; OR: 0.20; 95%CI: 0.012-0.035; p < 0.001).

In univariate comparison in exposure to risk factor to present a DVT in non-neoplastic patients between lower and upper limbs. The variable with p value lower than 0.05 were obesity (7.9% vs 21.4%; OR 0.31, 95% CI 0.09-1.04, p:0.04) and immobilization ( 7.9% vs 26%;OR 0.24; 95% CI 0.07-0.80; p: 0.01) in lower limbs; and oral contraceptives use (13.2% vs 5.2%; OR 2.85, 95% CI 1.00-7.69, p: 0.04) to present DVT in upper limbs. In the multivariate , the variable associated with presenting a DVT in upper limbs was oral contraceptive use (OR 2.42, 95% CI: 0.84-6.95, p 0.09).

Conclusion: Our cohort, neoplastic patients, is similar to that described in the current bibliography. DVT in the upper limbs is more frequency in neoplastic patients than in patients non-neoplastic. We have observed that contraceptive consumption use is associated with DVT in the upper limbs in patients non-neoplasic, this difference being maintained in the multivariate analysis.

                                               Asymptomatic carotid and vertebral arterial injuries in head and neck trauma - diagnostic approach in emergency department

                                                                                                                                     Dr Viacheslav Koshonko

Dr Mattia Kolletzek

Emergency department, Colchester General Hospital, Colchester, Essex, UK

Introduction

Blunt trauma to the head and neck is well recognised risk factor for carotid and vertebral arterial injuries.

Overall incidence of carotid and vertebral arterial injuries associated with head and C-spine trauma is highly variable in literature and accounts up to 30% of cases.

Significant proportion of such injuries may be initially asymptomatic.

In few cases it may lead to potentially fatal posterior circulation ischaemia and stroke.

Methods and materials

Retrospective observational study over 6 years (2011-2017). 

There were 19 patients included into this study, who presented to emergency department with high energy and dangerous mechanism of head and neck trauma and therefore had computed tomography of head and cervical spine followed by computed tomography angiography of aortic arch and carotid arteries.

No patients manifested signs of neurological deficit on examination at the time of their presentation to emergency department.