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00:00 - 00:00 #23041 - A novel approach to define the risk of intracranial lesions after a minor head trauma.
A novel approach to define the risk of intracranial lesions after a minor head trauma.

Background: The management in acute setting of patients with minor head trauma (MHT) still remains a matter of debate. The current guidelines and decision rules do not consider all the commonly known risk factors for post-traumatic sequences in a homogeneous and comprehensive manner. So they do not provide physician with concordant indications for CT scan, mainly in low-risk patients

Aim: The aim of our study was firstly to evaluate in a multivariate model each risk factor as predictor for the appointed outcome (CT positive or need for neurosurgery). Then these factors was used to create two predictive tools, a risk score and a nomogram, able to provide every single patient with MHT with an individual risk level for positive outcome.

Patients and methods: We prospectively evaluated all the patients observed for MHT from June 2016 to December 2017 and submitted to Ct scan in the Emergency Department of the University Hospital of Verona (Italy). The study population was divided in a creation (June 2016 to June 2017) and a validation dataset (July 2017 to December 2017). All risk factor proved to be significantly associated with outcome in univariate and multivariate analysis, at significance level p<0.05, were included in the final model to create a risk score. This score was further validated in an indipendent dataset by means of discrimination and calibration. The nomogram was developed from creation dataset using a multivariate logistic model and then validated as well as risk score.

Results: We enrolled 3479 consecutive patients (1983 males, 1496 females; mean age 64 years), forming the creation (2353 pts) and the validation dataset (1126 pts). An intracranial bleeding (outcome CT+) was detected in 316 patients (8.5%), but only 28 of them (0.7%) needed for neurosurgical intervention or intensivve care (outcome NS+). The eleven risk factors confirmed to be significantly related to outcome in the statistical analysis were included in the fianl model and a defined score, ranging from 1 to 4, was assigned to each factor. The total score ranged from 0 (no risk) to 26. In the ROC curve of risk score AUC was 0.809 (p<0.05), thus reaching a very high accuracy level. We reported a positive CT in all patients with score > 15 and in 82% with score > 12 (specifity 0.99, PPV 0.82). Instead, the 99.2% of patients with score < 2 and all those completely risk free (6.3%) had a negative CT (sensibility 1.0, PPV 1.0). Also the concordance index of nomogram appeared to be very high (AUC 0.802). Out of the 17 patients with probability > 0.8%, most of them (76.5%) were reported with an intracranial lesion (specifity 0.99, PPV 0.76). A probability of 0.1% was associated with a specifity of 83.2%, while in case of probability < 0.2% (87.9% of pts) specifity rate increased to 92.4%.

Conclusions: Our combined model allows to arrange every patient with MHT in an individual level of risk to develop intracranial lesions and represent an easy tool to support emergency physicians in better managing these patients.

Dr Antonio BONORA (VERONA, Italy), Gianni TURCATO, Alice DILDA, Chiara BELLESINI, Massimo ZANNONI, Antonio MACCAGNANI
00:00 - 00:00 #23474 - A severe case of Clarkson Syndrome complicated with cardiac arrest.
A severe case of Clarkson Syndrome complicated with cardiac arrest.

Systemic capillary leak syndrome, also known as Clarkson Syndrome, is a rare condition with a severe presentation and a potential fatal outcome. The disease is characterized by transient episodes of increased vascular permeability and leakage of plasma proteins to the interstitial space. The most important characteristics are: severe edema, tissue hypo-perfusion, hypoalbuminemia and hemoconcentration. We present a case of a 49-year-old woman who was admitted to the Emergency Department with anasarca and hypovolemic shock. She had been diagnosed with Clarkson Syndrome two years before but had no medical follow-up. The anamnesis found a history of diarrhea in the days preceding the first crisis as well as in the days preceding the current episode. The patient received massive fluid perfusion and intravenous noradrenalin but she had a cardiac arrest. She was resuscitated and admitted to the Intensive Care Unit. She further developed severe complications of the hypovolemic state: hepatic, intestinal and cerebral ischemia. She died of multi-organ failure after 15 days. The pathophysiology of the disease is poorly understood and the acute treatments are empirical. We describe a case of Clarkson syndrome as a rare cause of hypovolemic chock presenting to the Emergency Department with particular focus on the need of rapid solute resuscitation and adrenaline.

Oana Maria DAN (Paris)
00:00 - 00:00 #23606 - A systematic review on the need of anticoagulant therapy in subsegmental pulmonary embolism.
A systematic review on the need of anticoagulant therapy in subsegmental pulmonary embolism.

Background: The use of multirow detector computer tomography pulmonary angiography (CTPA) has increased the number of diagnosed subsegmental pulmonary embolism (SSPE). It is unknown if SSPE require the same treatment with anticoagulation therapy (AC) due to venous thromboembolic (VTE) recurrences, as acute pulmonary embolisms (PE). AC therapy carries the risk of major bleeding. Thus, it is important to know if patients with an SSPE requires AC therapy. The purpose of this systematic review is to investigate if it is safe to withhold AC therapy in hemodynamically stable patients diagnosed with an unprovoked SSPE.  

 

Methods: We conducted a systematic literature review, based on the PRISMA guidelines using the Pub.Med, Ovid Medline and Embase databases. Combined search using text strings: Subsegmental, SSPE, Pulmonary embolism, pulmonary thromboembolism, subsegmental PE, subsegmental thromboembolic disease, CT angiography, anticoagulant* was done. We further added several Medical Subject Headings to the search string. The search was conducted between January 1981 – April 2020. In addition, we conducted a snowball search by screening the title of the paper through all the references in the individual paper and then including the paper that seem to fulfill our inclusion criteria’s until no new references regarding our topic were to be found. 

 

We included: 1) Studies investigating the outcome of patients diagnosed with SSPE who did/didn’t receive therapy. 2) Only original studies included. 3) Studies that clearly defined SSPE. 4) Patients included in the study were ≥ 18 years of age. 5) The patients were hemodynamically stable. 6) No DVT. We excluded 1) Case reports or abstracts. 2) Studies investigate PEs based on an underlying factor (e.g. cancer, former history of PE or DVT, pregnancy, anticonception, thrombophilia). 3) Papers written in another language than: English, Danish, Swedish, Norwegian, German and French. All systematic reviews regarding SSPE and AC-therapy were excluded post snowball search due to duplication of patients already included in original studies in our review. The Selection of papers was performed by reviewing titles, abstracts and full texts. 

 

Results: 415 papers were identified. 82 removed due to duplication. 333 title and abstracts were screened. 37 papers were read in full (28 where systematic reviews). Snowball search identified one additional paper. 28 systematic reviews excluded leaving 10 papers for the final group discussion. Post group discussion and further analysis consisted of 6 papers. The 6 studies identified a total of 366 patients with SSPE.  123 patients did not receive any AC therapy. Among the 123 patients who did not receive AC therapy there were 0 VTE recurrence, 0 major bleeding, 0 VTE related mortality within 3 months follow-up.

 

Discussion & Conclusion: In our study the literature is limited, sample size small, 5 out of 6 studies are retrospectives.  All studies with total of 123 pts. who didn’t receive AC-therapy show 0 VTE recurrence, 0 major bleeding, 0 VTE related deaths within 3 months. Our review of the available literature till as of April 2020, shows that it is safe to withhold AC therapy in patients with single SSPE and no DVT.

Larshan PERINPAM (Herning, Denmark), Anders MOELLEKAER, Poul PETERSEN, Tommy ANDERSSON, Anna-Marie BLOCH MÜNSTER
00:00 - 00:00 #23744 - Acute renal failure and mortality in septic patients in the emergency department.
Acute renal failure and mortality in septic patients in the emergency department.

Background: Several data about the prevalence of acute renal failure (ARF) among septic patients are lacking. Further, it is not known whether ARF is an independent risk factor for mortality in septic patients or merely an indicator of disease severity.

 The goal of this study was to examine whether ARF is a risk factor for mortality in septic patients.

Methods: We conducted a prospective observational trial in emergency department.  All patients presented in ED with sepsis defined according the third international sepsis campaign and ARF were enrolled. ARF is defined by a rise in creatinine above twice the upper limit of normal and/or a drop in urine output to < 0.5 ml/kg bodyweight. Patients with chronic dialysis dependent renal failure were excluded from analysis.  

Results: One hundred eighteen patients were include. Among them 22 patients (18.6%) had chronic dialysis-dependent RF and 40 patients (41.66%) had ARF. septic Patients had an overall hospital mortality of 27%. Hospital mortality in patients with ARF was 67.3% and without ARF 42.8%. ARF remained a significant risk factor for death [p< 0.0001; OR= 0, 77, 95% confidence interval (CI) 0.258-2.327]. Mortality in septic patients was not associated with pre-existing, non-dialysis-dependent chronic kidney disease, whereas in dialysis dependent patients with sepsis mortality increased to 86%.

 

Discussion: In this representative survey in septic patients, ARF represents a significant risk factor for mortality in these patients.

 

Amira BAKIR (Tunis, Tunisia), Hana HEDHLI, Wafa SLAIMI, Rym BEN KADDOUR, Aymen ZOUBLI, Rym HAMED
00:00 - 00:00 #23597 - Adding lung ultrasound to standard management for patients with suspected COVID-19 presenting to the emergency department: development of a composite score for rapid respiratory decompensation (EchoVID study).
Adding lung ultrasound to standard management for patients with suspected COVID-19 presenting to the emergency department: development of a composite score for rapid respiratory decompensation (EchoVID study).

During the COVID-19 outbreak, a key-role of Emergency Department (ED) physicians is to safely discharge patients who won’t require hospital admission in the next few days. For that purpose, a normal clinical exam including normal oxygen saturation in room air is required but does not rule out an early potential respiratory decompensation. Chest X-Ray has a sensitivity of only 69% in detecting COVID-19 lung involvement. Lung Ultrasound (LUS) has demonstrated better diagnosis performance than chest X-Ray. Preliminary findings of LUS in COVID-19 showed promising results for improving diagnosis [7].

The aim of our study was to develop a composite score, clinical and LUS (EchoVID), predicting rapid respiratory decompensation in patient presenting to the ED with suspected COVID-19.

Patients and methods

The WINFOCUS-France group designed an electronic anonymized database used in 10 ED in France and Belgium since March 30, the VIRUS registry (Verification of Initial Respiratory signs with UltraSound). EchoVID is the first observational cohort study extracted from this database. For each patient presenting to the ED with suspect COVID-19, clinical and LUS characteristics were registered at ED presentation and clinical follow-up at Day 2 and Day 14. This study was approved by the Nantes University Ethic Committee and registered on clinicaltrial.gov (NCT04370249).

LUS was provided by trained operators. 6 zones were identified for data gathering: upper and lower half of anterior, lateral and posterior regions in each hemithorax. We used a scoring according to previously published LUS classification: ‘0’, no or less than 3 B-lines, ‘1’, 3 B-lines or more, ‘2’, multiple coalescent B-lines or ‘3’ lung consolidation. The global score was then calculated by summarizing results obtained for each region.

Rapid respiratory decompensation was defined at day 2 and day 14 by onset or increase in oxygen requirement, need for mechanical ventilation or death.

Statistical analysis was realized with R v3.6 and included multivariate logistic regressions with variables with p<0.2 in bivariate analysis.

Results

On April 23, 191 patients were included in the VIRUS registry. The sex ratio (F/M) was 1. A decompensation at D2 occurred in 26 (14% [CI95% 9-19%]) patients. In bivariate analysis, age range, body mass index, respiratory rate, oxygen saturation, qSOFA score and LUS score were significantly different between patients with or without decompensation. The area under the curve (AUC) of LUS score in ROC for a decompensation was 0.69. The logistic regression identified the following factors associated with decompensation at D2: current cancer, diarrhea, respiratory rate, oxygen saturation, qSOFA and LUS scores. The AUC in ROC was 0.91.

Discussion and conclusion

The major result was that the composite EchoVID score had better diagnosis performance than LUS score alone to predict D2 decompensation. However, these preliminary results on 191 patients need further statistical analysis to be performed on D2 and D14 decompensation occurrences. This by pursuing data gathering on VIRUS registry and EchoVID analysis in the next few months. Finally, we intend to develop and validate a algorithm in order to optimize the pathway of care, and especially to discharging safely low-risk patients.

Quentin LE BASTARD, Christophe PERRIER, Elise CARIE, Christophe BERRANGER, Philippe PES, Arnaud LEGRAND, François JAVAUDIN, Tomislav PETROVIC, Philippe LE CONTE (Nantes)
00:00 - 00:00 #23220 - Ambulatory care : A TIME AND PLACE.
Ambulatory care : A TIME AND PLACE.

INTRODUCTION:  

A new approach to ambulatory care was introduced in Beaumont Hospital on May 3rd  2019The  patients who  historically would have been admitted to a ward bed for investigation and treatment had their care fast tracked” in the Emergency Department. Patients in this ambulatory pathway are under the care of the relevant on call service but nursed by the Emergency Department nursing staff in the Emergency Department. A Clinical Nurse Manager was appointed to help expedite the investigations and coordinate the care of patients undergoing ambulatory care. For these patients radiology investigations (MRI, CT, US, Xray) and laboratory investigations were prioritised to facilitate quick decisionmaking. This study was performed to assess the impact of this intervention on Emergency Department performance indicators and patient care. METHODS: 

Data was gathered from the Emergency Department information system on all attendances to the Emergency Department from 1/5/2019 to 31/8/2019. Data was analysed using an excel spreadsheet. Descriptive statistics are used to present the data. Data on the patient experience times of those on the Ambulatory pathway was compared with those not requiring admission and those admitted to the wards under the on call services.

RESULTS:  

The number of presentations to the ED over the four month study period was 19,789 of whom 857 patients were placed on the ambulatory pathwayDuring the study period the average PET for patients discharged by the Emergency Medicine team without onward referral  (11,436) was  6 hours 32 minutes. The average time in the Emergency Department for patients referred to the on call services (6482) was 14 hours and 4minutes. The average time in the Emergency Department for the 857 patients  on the ambulatory pathway was 21 hours 53 minutes with 326 (38%) spending more than 24 hours in the ED. 46% (398) of those on the ambulatory pathway went on to ward admission. Of the ambulatory patients where no bed request was generated their average length of stay in the ED was 19 hours 13 minutes with 71 (25%) being there in excess of 24 hours.

 

CONCLUSIONS: 
Patients on the ambulatory pathway spend an average of 21hours 53 minutes in the Emergency Department of whom 46% require admission to a ward bed. Of great concern is the fact that 38% of ambulatory patients are in the ED for in excess of 24 hours. Ambulatory care does have a time and place but it should be performed in an appropriate setting and appropriately resourced. Care that utilises clinical space in an already crowded ED and uses nursing resource in a busy Emergency Department should be provided in an ambulatory care area and not in the ED.

Octav CRISTIU (Duleek, Ireland), Gilligan PEADAR
00:00 - 00:00 #22848 - Ambulatory Care Score for Atrial Fibrillation: a score for decision support of new-onset atrial fibrillation in an emergency department without cardiological advice, a prospective, observational, comparative and monocentric study.
Ambulatory Care Score for Atrial Fibrillation: a score for decision support of new-onset atrial fibrillation in an emergency department without cardiological advice, a prospective, observational, comparative and monocentric study.

Background: Ageing population increase prevalence of atrial fibrillation (AF). It leads to significant health care resource use, essentially because of hospitalizations cost. Based on European and French recommendations, we built ACSAF (Ambulatory Care Score for Atrial Fibrillation) for ambulatory management without cardiological advice in an emergency department (ED). It includes 8 items: age > 75 years old, heart failure, myocardial infarction, chronic kidney disease, valvular atrial fibrillation, AF < 48 hours, bleeding risk with anticoagulation, heart rate, trigger factor. The main objective of the study is to develop a score for new-onset atrial fibrillation (NOAF) management in an ED without cardiological advice in comparison with cardiological advice (gold standard). The secondary objectives are to evaluate cardiological follow-up and rehospitalization.

Methods: This prospective, observational, comparative and monocentric study was realized from November 2018 to October 2019. All patients aged 18 years old and older with NOAF were included. Patients with systolic blood pressure < 80 mmHg or heart rate > 180 bpm were secondarily excluded. Clinical and paraclinical data for calculation of ACSAF were recorded. Calculation of ACSAF was made in blind of orientation decision during the ED visit. Follow-up within 3 months consists of a phone interview for data collection of cardiology visit, delay and rehospitalization. The primary outcome is the mean of ACSAF between ambulatory care group and hospitalization group with the ROC curve to search the best threshold. The secondary outcomes are the cardiology visit rate, mean of delay and rehospitalization rate between ambulatory care group and hospitalization group.

Results: 81 NOAF was included, aged 69 ±16 years old, including 42 men (51,9 %). ACSAF is higher in hospitalization group 2,16 ± 1,05 against 1,03 ± 0,97 in ambulatory care group (p < 0,05). The optimal ACSAF threshold is 2 with a sensibility of 71,4% IC95% [57,1-83,7] and a specificity of 81,2% [68,8-93,8]. The area under the ROC curve of ACSAF was 0,70 IC95% [0,70-0,89]. The comparison between ambulatory care and hospitalization group is significantly different for variables in relation with items of ACSAF. 69 patients could be called within 3 months (30 in ambulatory care group and 39 in hospitalization group), 27 patients (90%) had a cardiological visit in ambulatory group against 23 (59 %) in hospitalization group (p< 0,05) without an increase visit delay (66 days ±62,6 in ambulatory group vs 56,4 days ±45,7 in hospitalization group; p=0,55). 3 patients (10,3 %) was readmitted in ambulatory care group against 17 patients (43,6%) in hospitalization group (p<0,05).

Discussion & Conclusion: ACSAF allows to determine orientation for NOAF during the ED visit without cardiological advice. Follow-up is better in ambulatory group than hospitalization group, and less rehospitalization within 3 months.

Constance MICHIELS, François OUTTERYCK, Perrine LIBERT, Carole GODESENCE, Rémy DIESNIS (Roubaix)
00:00 - 00:00 #22607 - Analysis Of The Causes Of Severe Trauma In The Population With And Without Trauma Induced Coagulopathy.
Analysis Of The Causes Of Severe Trauma In The Population With And Without Trauma Induced Coagulopathy.

Premise and goals: Severe trauma is the first cause of death worldwide for patients of age 40 or less. About 30% of severe trauma patients presents with trauma induced coagulopathy at arrival to the E.D. About 40% of trauma deaths are related to bleeding, a quarter of which seems preventable.  The goal of this study is to determine if patients with coagulopathy present with more severe anatomical injuries.

Methods: We conducted a monocenter prospective observational study involving all patients affected by severe trauma in the Emergency Department of the Fondazione Policlinico IRCCS S. Matteo in Pavia in 12 consecutive months: from the 1st of January 2018 to the 31st Decembe 2018. All patients registered as affected by severe trauma in our Emergency Depatment have been enrolled. Inclusion criteria are to satisfy at least one of the pathognomic classification criteria for severe trauma as defined by the American College of Surgeons, Advanced Trauma Life Support (ATLS@) and approved by regional deliberation...

These criteria are: Physiopathological Criteria (compromised health parameters or necessity for advanced life support); Anatomical Criteria (e.g. puncturing wound to the head, neck, thorax or abdomen); Mechanism of Injury Criteria (e.g. ejection from vehicle, death of an occupant in the same vehicle...).
We considered patients affected by coagulopathy if positive for at least two altered biochemical values traditionally used to study coagulopathy.
Patient undergoing an anticoagulant therapy have been excluded.

Results:  We evaluated 503 patients in total.
204 were affected by trauma induced coagulopathy (80% of which males) with an average age of 44 years and peak incidence between 55 and 65 years old; Of the patients affected by coagulopathy, 91% satisfied MOI criteria, 22% anatomical criteria and 15% physiopathological criteria.
299 were not affected by coagulopathy (68% of which males) with an average age of 43 years and peak incidence between 25 and 35 years old; of these patients, 91% satisfied MOI criteria, 10% anatomical criteria, 8% physiopathological criteria.

Trauma causes among patients affected by coagulopathy are: 68% traffic accident, 8% domestic accident, 3% self inflicted injury, 3% work related injury, 0.5% violence, 5% other.

Trauma causes among patients not affected by coagulopathy are: 77% traffic accident, 8% domestic accident, 2% self inflicted injury, 6% work related injury, 0.3% violence, and 3% other.

Conclusions: Among the vast sample from us considered, there is no significative causative difference between trauma patients who develop trauma induced coagulopathy and those who do not. 

Dr Gabriele SAVIOLI (PAVIA, Italy), Sarah MACEDONIO, Mirko BELLIATO, Fabrizio CUZZOCREA, Guido FORINI, Matteo GHIARA, Federica MANZONI, Sabino LUZZI, Mattia DEL MAESTRO, Maria Antonietta BRESSAN, Mario MOSCONI, Cesare PEROTTI, Alessandra LIVRAGHI, Iride Francesca CERESA, Giorgio Antonio IOTTI
00:00 - 00:00 #22843 - Are children presenting to the paediatric emergency department with acute wheeze being appropriately followed up in primary care?
Are children presenting to the paediatric emergency department with acute wheeze being appropriately followed up in primary care?

Title

 

Are children presenting to the paediatric emergency department with acute wheeze being appropriately followed up in primary care?

 

Background

 

Viral wheeze and acute exacerbations of asthma are one of the commonest ED presentations amongst the paediatric population. Whilst the vast majority of these children are treated successfully and discharged home, a further problem arises from their aftercare. 

 

Many children with asthma have poor control of their condition, often as a consequence of poor compliance to preventative therapy. We estimate that that 75% of hospital admissions for asthma and as many as 90% of the deaths from asthma are preventable.

 

Most patients can achieve effective control of their asthma in partnership with primary care. Current British Thoracic Society (BTS) guidelines state that “prior to discharge, follow up should be arranged with the patient’s general practitioner or asthma nurse within two working days”, with the aim to prevent further emergency admissions by exploring factors that contribute to poor self-care.

 

Aims

 

This study was based in St. Georges University Hospital in South London – a tertiary hospital with a dedicated paediatric emergency department and respiratory team, who were involved in the care of 316 children presenting with acute wheeze in 2019. The aim of this project was to elicit what proportion of patients presenting with acute wheeze were followed up within 2 working days in primary care, and what was contributing towards their non attendance.

 

Methods

 

We performed a retrospective quantitative study, obtaining a consecutive sample of children and young people aged between 1 and 18 years with a final diagnosis of Asthma or Viral Wheeze. These patients should have received repeated doses of bronchodilators and/or steroids to warrant a review within 2 days. 

 

From this patient cohort, their respective general practice was contacted to elicit whether the patient attended within 2 working days and the rationale for their attendance.

 

Results

 

There were 51 paediatric patients presenting with acute wheeze between the 30th August and 19th September 2019, of which 45 warranted a review in primary care within 2 working days. Only 20 (44.4%) received appropriate follow up by their GP or Asthma nurse. For the remaining 25 patients, 11 had difficulty getting access to an appointment on time, 2 had a telephone consultation instead, and 11 were unexplained. We also found deficits in documentation where 19 patients failed to have discharge summaries prompting GPs for the need of a review.

 

Discussion and Conclusions

 

This study highlighted that most children presenting to ED with acute wheeze were unable to attend a follow up appointment in primary care within 2 working days. We are in the process of engaging with key stakeholders to highlight and address what barriers are contributing towards these difficulties, as part of a quality improvement project in the trust. The hope is that we can emphasise the importance and awareness of the review to patients and primary care through education, clear channels of communication and facilitating access to GP appointments.

Sanjoy ROY (London, United Kingdom), Rhys BEYNON, Richard CHAVASSE, Joanne LAWSON
00:00 - 00:00 #23538 - Are we using NICE guidelines appropriately for CT head of Head Injury patients?
Are we using NICE guidelines appropriately for CT head of Head Injury patients?

Background

CT head/Neuroimaging formulates one of the key investigations to guide the diagnosis, management and prognosis of head injuries. Head injury is the commonest cause of death and disability in people aged 1-40 years in the United Kingdom. This study evaluated whether we were appropriately using NICE Guidelines to assess head injury patients by performing CT head.

 

Methods

A single centre retrospective study was carried out looking at patients attending the Emergency Department in August 2019 with suspected head injury.

102 patients were identified using iCare and data collection was completed using FirstNet and PACs.

 

Results

Total of 102 patients fit the criteria out of which 40 patients had CT head. 20 out of 40 patients fit the criteria for CT head as per NICE guidelines. Mean time to be triaged in ED was approximately 25 minutes. Mean time to be seen after triage was approximately 2 hours. CT head performed within 1 hour of request was 36% and CT head performed within 1 hour of triage was 7%. CT head reported within 1 hour was 75%.

 

Discussion and Conclusion

This retrospective study showed that doctors and nurses are not compliant with the NICE guidelines as 50% of CT head were done when it was not warranted. CT head was not being performed within the 1st hour of head injury presentation: delay of approximately 2-hour 20minutes between triage and assessment by a medical practitioner. 75% of data suggest CT head was being reported within 1 hour, which is compliant with NICE guidelines. Moreover, it was impossible to say whether some of the risk factors such as seizures, loss of consciousness or amnesia was not assessed or merely not documented. This data suggested that an intervention is required to improve the documentation process and compliance of doctors and nurses in order to improve the delays between triage, assessment and performing CT head. Furthermore, by reducing the unwarranted CT heads performed the emergency department can save money and patients can be spared from unnecessary exposure to radiation. Hence, we are implementing two quality improvements projects in order to address the above issues and then re-audit.

Badrun SHUROVI (London, United Kingdom), Nadeem NAYEEM, Gautam PRAJAPATI
00:00 - 00:00 #22922 - Assessment of the influence of air pollutants on the number of Emergency Department visits due to asthma exacerbation in a small city.
Assessment of the influence of air pollutants on the number of Emergency Department visits due to asthma exacerbation in a small city.

BackgroundThe link between increased air pollutant levels and worsening of chronic respiratory diseases is widely known. Particularly, asthma exacerbation is among the most established associations between air quality and disease, responsible of a number of outpatient visits and hospital admissions every year. Nevertheless, most of the studies in this context focus on big cities with great pollution while the influence of lower pollutant levels is scarcely investigated.

Aim. Assessing the influence of air pollution levels on the number of Emergency Department (ED) visits due to asthma exacerbation in Valladolid, a small city in Spain.

Material and methods. ED visits due to asthma worsening were collected from January 2010 to December 2018 in the Río Hortega University Hospital of Valladolid (Spain). Air pollutants (NO, NO2, CO, O3, PM10, PM2,5) were obtained from the monitoring stations of the Valladolid City Council. Temperature and rainfall were included in the study as potential confounding factors. The association between each pollutant and the number of ED visits was analyzed using linear regression with Poisson distribution. In order to assess the potential delayed influence of pollution, both daily values and the peak value within four time-lags prior exacerbation (0, 1, 3, and 7 days) were used to characterize air quality.

Results. A total of 2527 visits from 1588 patients were collected. By means of univariate analyses, temperature and month raised as confounding factors. Accordingly, using them as covariates, statistically significant association with ED visits was found for particulate matter with a diameter less than 2.5 micrometers (PM2.5: OR 1.006, 95%CI 1.000-1.011; p <0.05), nitrogen oxide (NO: OR 1.002, 95%CI 1.000-1.004; p <0.05), nitrogen dioxide (NO2: 1.005, 95%CI 1.001-1.010; p <0.05), and ozone (O3: OR 0.997, 95%CI 0.994-1.000; p <0.05). The pollutants reached its highest influence on different time lags. A time lag of 3 days maximizes the link between increased ED visits and NO2(average value 3 days ago), NO and O3 (peak value 3 days ago) while for PM2,5 the association was maximum considering the peak value 1 week ago. 

Conclusion. Our findings suggested a connection between NO, NO2, O3, and PM2,5 levels within the last week and the number of ED visits due to asthma exacerbations. This association is also significant even in a small city with moderate pollutant levels.

Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Cerezo-Hernandez ANA, Daniel ALVAREZ, Moreno FERNANDO, Del Campo FELIX, Virginia CARBAJOSA RODRIGUEZ, Jesus Angel MOCHE LOERI, Jesus ALVAREZ MANZANARES, Susana SANCHEZ RAMÓN, Laura FADRIQUE MILLAN, Inmaculada GARCÍA RUPEREZ, Henar BERGAZ DIEZ, Irene CEBRIAN RUIZ, Isabel GONZALEZ MANZANO, Samsara LOPEZ, Mª Antonia UDAONDO CASCANTE, Francisco MARTÍN RODRIGUEZ
00:00 - 00:00 #23104 - Assessment of withholding or withdrawing life-sustaining treatment decision in Emergency department.
Assessment of withholding or withdrawing life-sustaining treatment decision in Emergency department.

Background

Withholding or withdrawing life-sustaining treatment decisions have to be made right from the emergency department. Terminal patients or patients with acute disease and vital prognosis engaged are concerned. This situation remains complex.  A working group wrote and has implemented an enquiry to be completed for all patients who the physician decided a withholding or withdrawing life-sustaining cares. In a first part, autonomy, comorbidities and acute situation, patient’s desire, family contact and wishes are collected and who make the decision. In the second part we can find a list of different cares (cardiac monitor, urinary probe, antibiotics, transfusion, cardiac resuscitation…) the monitoring and the possible prescription of pain killer and sedation.

The aim of study is the assessment of this document.

Methods

It’s an observational, monocentric and retrospective study from 01/01/2018 to 31/12/2019.

A file is completed for all patients who have withholding care decision. The data collection was made by a senior doctor and a copy of the enquiry was made.

Results

84 files were recovered. 52% were women. Middle and mean age were respectively 85 and 89 year old [48-104]. 45% had respiratory distress, 27% neurological failure, 14% septic shock, 6% heart failure, 3% hemorrhagic shock. Glasgow Coma scale when the decision was made was less than 13 in 72.6% of patients. 19 patients (22.6%) had an active cancer and 5 had even palliative care decision. 89% had a limited autonomy and 39% had cognitive disorders. In 67.8% of patients, ICU physician was called. Withholding or withdrawing life-sustaining treatment decision was in all cases a collegial medical decision. In 14% of cases, patients were concerted, family in 84.5% and paramedical team in 63%. For all patients, no intensive care unit (ICU) admission and no invasive care were decided, for 27 patients (32%), sedative and morphine prescription was immediately introduced.  For 12 patients, all the therapeutics was stopped. 61 patients (72.6%) have died during hospitalization, 21 the first day.  2 patients refused admission and were discharge after the consultation. 16 patients (19%) went back home. Their middle length of stay was 9 days.

Discussion and conclusions

Withholding or withdrawing life-sustaining treatment decision is a part of the emergency physician’s job. It’s a balance between medical ethics and patient’s desire. Pain, lack of therapy, airway management, length and quality of life should be considered. In this study there is two types of patients : a part of them had a vital prognosis immediately engaged, the second part are patients with serious pathology and the decision is maximal medical care but no cardiac resuscitation and non ICU admission if deterioration.

The implementation of this enquiry in our department was agreed by all the team and the fact to complete the file is not equivalent of death. The collegial decision and the family implication improve the communication and the care’s organization.

Christelle HERMAND (Paris), Cécile CHAUVEAU, Muriel CHAILLET, Emilio ALVAREZ, Bleuenn BRUNET, Aurelie LEFEVRE, Youri YORDANOV
00:00 - 00:00 #23415 - Association between homecare and readmission rates among elderly acutely admitted patients – a register-based study.
Association between homecare and readmission rates among elderly acutely admitted patients – a register-based study.

Background: Acutely admitted patients who are dependent on homecare may be especially challenged with regard to readmissions and mortality. The aim of this study was to assess the association between number of hours of received homecare and readmission and mortality after an acute admission in an Emergency Department (ED).

 

Methods: This study was planned as a register-based cohort study. Data were extracted from Danish registers through Statistics Denmark to construct a database on readmission rates and associated variables. We included all patients above 65 years living in Denmark with an acute admission to any hospital in Denmark, from 1st of December 2016 to 30st of November 2017. We include all acute admissions, registered as in-patients, with a length of stay ≤ 48 hours to represent the majority of patients discharged directly from an ED. Patients living in caring-home and patients without Danish citizenship were excluded. The primary outcome was readmission, defined as an acute, unplanned contact, registered as in-patient or out-patients, within 30 days from the index admission. Secondary outcomes were mortality after 30 days and 180 days. Descriptive statistics were used to describe age, sex, marital status, income and whether they received community nursing care and physiotherapy. Logistic regression analyses were used to clarify the association between use of homecare (hours a week) and readmissions and mortality. Comorbidity, diagnosis, use of medication for mental illness, and length of stay were included as confounders.

 

Results: In total 177,109 patients had an acute admission during the one year period. Of these, 83,653 met the inclusion criteria. Mean (SD) age was 77(8) years, 51 % were female, 54 % were married and mean (SD) length of stay was 19(13) hours. Among these patients, 20 % received homecare, 13% received community nursing, and 4 % received physiotherapy. The analyses are expected to be completed in October.

 

Conclusion: Knowledge about the risk profile of patients who are dependent on homecare can be used to organize and coordinate patients’ different contacts at the hospital. Furthermore, knowledge about their risk of readmission and mortality may, in combination with the patient’s wishes, be used to develop care and treatment interventions to be implemented in collaboration between the ED and primary sector.

Mette ELKJÆR (Aabenraa, Denmark), Jette PRIMDAHL, Mikkel BRABRAND, Christian BACKER MOGENSEN, Bibi GRAM
00:00 - 00:00 #22728 - Audit of the quality of referral letters from general practice to emergency department; a solution ready and waiting.
Audit of the quality of referral letters from general practice to emergency department; a solution ready and waiting.

Inconsistency among referral letters from General Practice (GP) to Emergency Departments (ED) was addressed by the Irish College of General Practitioners (ICGP) and the national General Practice Information Technology (GPIT) group in 2010, resulting in formulation of a National Referral Template compatible with four major GPIT-accredited practice management systems used throughout Ireland, or which can be utilised in paper format. The goal of standardising referrals was to ease this process for GPs through use of a streamlined template, whilst ensuring doctors receiving patient care are provided with accurate, and relevant clinical and adminstrative data, in a legigible and organised fashion, to allow optimal patient assessment and interpretation of findings. The template was recommended by the Health Information and Quality Authority (HIQA) in their 2011 report. We undertook an audit aimed at examining quality of GP referral letters to Cavan General Hospital (CGH) ED, including Paediatric Assessment Unit, over a 1-month period, and determinig need to highlight existence of this recommended referral form to GPs in the catchment area, so as to improve patient flow and care in ED.

 

The National Referral Template published on ICGP/HIQA websites was used as the comparator. Sections, and in some instances subsections, of the template were allocated a score of 1, to total maximum score of 12 for fully-completed referral letters. Every patient record registered in CGH ED from 01/07/18-31/07/18 inclusive was individually analysed for mode of presentation, and all GP referrals were further studied for scoring and to compare accuracy of information with that recorded in ED notes. In cases of handwritten letters, whereby information was deemed illegible by three doctors, a score of 0 was allocated to the section/subsection. Data was collected in Excel spreadsheet. After data accumulation and interpretation, a generic letter detailing audit results was compiled and sent to GPs in the catchment, along with a copy of the National Referral Template and instructions on where to find these resources online, along with GPIT/HIQA reports supporting its use. After a 6-week period, re-audit was performed on 150 randomly-selected patients presenting to ED.

 

2,612 patients presented to ED during first audit cycle; 1,698 patients self-presented [1,326 walk-in, 372 ambulance], and 914 patients were referred by GP [873 walk-in, 41 ambulance]. Average score for GP letters to ED was 7.24 on this first cycle. Certain areas of information were identified as consistent omissions, including past history/medications/allergies/social history. Quality of letters were also found to vary between patient populations; letters for paediatric patients were overall higher-scoring, compared with adult/geriatric patients.

A total of 150 patients were analysed for re-audit; 78 patients self-presented [70 walk-in, 8 ambulance], and 72 patients were referred by GP [68 walk-in, 4 ambulance]. Average score for second cycle was 7.47, showing no statistically significant difference after the intervention.

 

Despite extensive nationwide endeavours by GPIT/HIQA to standardise referrals to ED, and our direct efforts to surrounding GPs, much work remains to increase GP acknowledgement of the National Referral Template, and to create awareness about importance of informative, accurate letters to ED.

Chloe DORAN (Dublin, Ireland), Gillian MAGUIRE
00:00 - 00:00 #23421 - Being creative during a neonatal resuscitation effort – A case report of an epidural catheter being used as an umbilical vein catheter.
Being creative during a neonatal resuscitation effort – A case report of an epidural catheter being used as an umbilical vein catheter.

Brief clinical history: A 32-year-old gravida 2 para 1 woman at 36 weeks of gestation presented at the Emergency Department with vaginal hemorrhage due to severe placenta abruption and fetal distress. She was immediately transferred to the operating theater where she underwent emergency caesarian section under general anesthesia. The infant had an Apgar score of 5/10 one minute after birth. We performed pharyngeal suction due to presence of blood and since the infant remained in distress, we proceed to intubation. In order to be safely transferred to the nearest hospital with a NICU, which is approximately 60 minutes away, we decided that it was necessary to secure vascular access. After multiple unsuccessful attempts of peripheral vein cannulation, we discussed the possibility of umbilical vein catheterization.

Misleading elements: Obtaining vascular access is a crucial and demanding task during neonatal resuscitation. Since it is an extremely rare event outside a Neonatal Intensive Care Unit (NICU), many hospitals, including ours, do not have the appropriate equipment needed.

Helpful details: The umbilical vein can be found through the exposed umbilical stump, where it has to be distinguished from the two umbilical arteries by its position at the head end, the thinner wall and the larger lumen. It can be cannulated by a 5Fr (=1,667mm external diameter) catheter in the case of a full-term infant (over 1500gr) or a 3.5Fr (=1,167mm external diameter) catheter in pre-term infants (less than 1500gr).

Differential and actual diagnosis: Since the hospital wasn’t equipped with specialized UVC kits, we attempted to insert an epidural catheter, instead. An epidural catheter is a sterile atraumatic flexible multi-orifice 19-gauge catheter (≈1,1mm external diameter) used for continuous infusion to the epidural space. The attempt was successful and the infant was transferred to the nearest NICU where the catheter’s positions was confirmed with an X-ray.

What is the educational and/or clinical relevance of the case? Informed consent by patient’s parents was obtained in order to report the case. Infants requiring vascular access is an extremely rare event outside the NICU. It is recommended by the European Resuscitation Council neonatal guidelines that umbilical vein catheterization is a viable technic to secure central venous access for infants up to 14 days old. Although the preferred technique for obtaining vascular access remains peripheral vein catheterization, this is not always a choice. The past few years, intraosseous route has gain acceptance during emergency cases for adult and pediatric resuscitation. The use of this technic is also restricted by the availability of the appropriate devise and practitioners’ knowledge. Resuscitation of a neonate in low-resources setting requires competency in the use of the available equipment and adaptability of the provider.

Anastasia SPARTINOU (HERAKLION, Greece), Vasiliki BIMPI, Fragkiskos MARAGKOUDAKIS, Paris ANAGNOSTOPOULOS
00:00 - 00:00 #23674 - Building Blocks for faster better patient care.
Building Blocks for faster better patient care.

Fascia Iliaca nerve block with local anaesthetic is recommended to achieve safe and timely analgesia for patients with fracture proximal neck of femur. In our hospital, performing a fascia iliaca nerve block is part of our care pathway for patients when a fracture proximal third of femur is confirmed on x-ray. The national guideline for this block was developed in our department and all doctors receive training in how to perform it. With reconfiguration of trauma services in Ireland, our department is now receiving trauma bypass patients and we have had an average increase in presentations by three per week.

Use of local anaesthetic minimises the requirement for opiate analgesics which can cause significant adverse events in this patient population. Delays in delivering a nerve block can mean patients are given opiate analgesia in the interim period until a nerve block can be given. 

Aims

We aimed to 

1. Audit current practice in our department in delivering pain relief including fascia iliaca nerve block to patients presenting with proximal third of femur fracture.

2. Identification of factors delaying nerve block delivery.

3. Introduce a designated fascia iliaca nerve block trolley to our department that contained a hand-held ultrasound and all the equipment necessary to administer the nerve block.

4. Re audit our practice.

Methods 

We performed a retrospective audit of all patients presenting with proximal third of femur fracture between October and December 2019 inclusive (following introduction of trauma bypass). We then introduced a designated fascia iliaca nerve block trolley and re audited our practice. The trolley contains a hand-held ultrasound machine and the specific equipment detailed in our fascia iliaca block guideline (attached).

Results

Pre-block trolley results

Nerve block performed in 86% of patients with proximal third of femur fracture.

Time to block was on average 50 minutes.

Concurrent use of opiate analgesia in 60%.

Average pain score at 2 and 4 hours 6/10.

The top two factors identified in causing delay to nerve block delivery were

1. Availability of the ultrasound machine

2. Gathering equipment

Post block trolley results

Nerve block performed in 96% of patients with proximal third of femur fracture.

Time to block was on average 15 minutes.

Concurrent use of opiate analgesia in 5%.

Average pain score at 20 minutes and 4 hours 2/10.

Conclusion

Introduction of a designated fascia iliaca nerve block trolley in our department reduced time to delivery of the block by an average of 35 minutes and a reduction in concurrent opiate use, which causes significant adverse events in this patient population. 

Additionally, using the block trolley was associated with a reduction in patient pain scores measured at 20 minutes and 4 hours.

Introducing a designated fascia iliaca block nerve trolley is useful for providing faster better patient care for patients with proximal third of femur fractures. Furthermore, we speculate if we could use our mobile block trolley to effectively deliver the nerve block on ambulance trolleys as the patient arrives to the ED i.e. prior to x-ray in overt cases.

Victoria Claire MEIGHAN, Emma May CURRAN (Dublin, Ireland)
00:00 - 00:00 #23694 - C-reactive protein and peripheral partial oxygen pressure can predict the need for hospitalization in COVID-19 patients admitted in Emergency Department.
C-reactive protein and peripheral partial oxygen pressure can predict the need for hospitalization in COVID-19 patients admitted in Emergency Department.

Background: Coronavirus disease (COVID-19) has been spreading around the world like a dramatic pandemic, the wide spectrum of clinical variability ranging from asymptomatic patients to critical ones. Since the frequent respiratory involvement could develop into a rapid and often unexpected manner into acute respiratory distress syndrome (ARDS), to promptly identify which patients need for timely hospitalization and intensive care is a crucial issue. Several studies have already assess the relationship between laboratory abnormalities and outcome in COVID hospitalized patients, but none of these has been carried out in acute setting.

Aim: The aim of this prospective observational study was to investigate whether simple and easy to collect clinical and laboratory findings could affect the choice between admission and discharge in COVID patients.

Patients and methods: We carried our study in the Emergency Department (ED) of the University Hospital of Verona (Italy) between 16th and 31th March 2020, considering all consecutive patients with SARS-CoV-2 detection by polymerase chain reaction in nasopharyngeal swab. Patients were then enrolled if fullfill one or more of these symptoms: fever equal or more than 38°, cough, shortness of breath, tachypnoea. In all patients medical history and risk factors and underlying conditions likely affecting the course of disease were reported and blood gas analysis, laboratory examinations and chest x-rays were performed. At the end of ED evaluation physician decided for patient discharge or admission. All discharge patients were followed until disease resolved without sequel.

Statistical analysis: Sensitivity, specifity, positive predictive value (PPV) and negative predictive value (NPV) were derived from the receiver operating characteristic (ROC) curves and analysed. The optimal cut-off values of biomarkers were established by ROC curves and cut-off values for each parameter affecting hospitalization were calculated from the areas under ROC curves (AUC). The groups were compared with Mann-Whitney test and proportion of patients with Chi-square test. Difference set at p<0.05 was considered significant.

Results: Out of 190 positive for SARS-CoV-2, 109 symptomatic patients (69 males, 40 females; mean age 67 years, range 27-93) formed the study population. After ED evaluation, 86 patients (78.9%) were admitted, while 23 (21.1%) were discharged and then healed without sequel. The variables more significantly related with hospitalization were: age, partial oxygen pressure (pO2), percutaneous oxygen saturation (SO2), C-reactive protein (CRP), white blood cells count (WBC) and imaging positive for pulmonary infilatrates (p<0.001). The rispective cut-off values were: age over 60 years (95% CI 0.78-0.95, PPV 95.9%), pO2 less than 72 mmHg (95% CI 0.90-0.99, PPV 98.7%), SO2 less than 97% (95% CI 0.83-0.95, PPV 96%), CRP superior to 19 mg/l (95% CI 0.89-0.99, PPV 96.4%), WBC superior to 5.8 x 109/l (95% CI 0.65-0.88, PPV 92.4%) and positive chest x-rays (95% CI 0.60-0.90, PPV 91.9%). We reported the higher hospitalization rate for pO2 (167 times) and CRP (108 times) respectively.

Conclusion: The values of pO2 and CRP appeared to be a simple a reliable prognostic factors and could support ED physicians in the short-time decision to admit the COVID patients.

Irena KOSTIC, Dr Antonio BONORA (VERONA, Italy), Alessia OLIVATO, Barbara MELCHIORETTO, Eleonora ZACCARIA, Antonio MACCAGNANI
00:00 - 00:00 #23027 - Can S100B be used as a point-of-care test to allow UK health care professionals to safely avoid CT scans in mild traumatic brain injury?
Can S100B be used as a point-of-care test to allow UK health care professionals to safely avoid CT scans in mild traumatic brain injury?

Background

The “silent epidemic” of traumatic brain injury (TBI) is the biggest cause of death for those under 40 years old in the UK. Mild TBI (mTBI) is defined by a GCS score of 13-15 and is a common presentation to the Emergency Departments (ED). In certain situations, patients with mTBI will require a head CT scan as recommended by NICE guidelines to rule out an intracranial haemorrhage.

CT scans are readily available in most EDs but they still impose a significant amount of ionising radiation and can be sometimes challenging to perform in patients with underlying learning difficulties, dementia, alcohol intoxication or concurrent anticoagulant therapy.

S100 calcium binding protein B (S100B) is a glial-specific and expressed primarily by astrocytes, and is released following a head injury. It is one of the most studied biomarkers in TBI with several published studies.

Methods

This systematic review evaluated the potential use of S100B as a point-of-care (POC) test in mTBI in reducing the need for CT imaging.

PubMed, Scopus and Cochrane Library were used to look for English language cohort studies and control trials published up to February 2020 on S100B release on mTBI injury in humans. Duplications were removed and articles were assessed out of a total of 303 results.

26 studies were consequently selected for analysis. The studies were categorised according to their aim: determining reliability of S100B (n=21) and comparison of S100B against other markers (n=5).  

Results

A cohort of 7,434 patients were enrolled into 26 studies. The majority (n=18) produced results that were in support of S100B being a clinically reliable point of care (POC) test for mTBI – owing to its high negative predictive value and sensitivity. From 15/18 papers, S100B had an average sensitivity of 95.4% (range 83.3%-100%) and a specificity of 32.2% (range 2%-100%). However, 5 studies also compared S100B against other well-known neuro-biomarkers and found that they were more clinically appropriate biomarkers such as glial fibrillary acidic protein (GFAP) (n=4) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) (n=1). 3 papers concluded that S100B was not a suitable clinical biomarker for reducing CT scans as they found that it: is only good in combination with other biomarkers (n=1) and has limited accuracy when blood samples are collected greater than 3 hours post-mTBI (n=2).

Conclusion

Research into S100B and its potential use in clinical decision making has produced some ground-breaking results. The promising results of this systematic review suggest that S100B should have a place in the UK guidelines for mTBI management in the near future. Nonetheless, it is felt that more studies must take place to confirm its reliability. A cohort study using well-defined S100B reference ranges, larger sample sizes, and serum sampling within 3 hours post-injury could be used to establish how much S100B can reduce the use of head CT scanning.

Jayden GITTENS, Abigail CLYNCH, Abdo SATTOUT (Liverpool, )
00:00 - 00:00 #22911 - Care cascade comparison of HCV mono-infected and HIV/HCV co-infected patients participating in a non-targeted emergency department HIV/HCV screening program.
Care cascade comparison of HCV mono-infected and HIV/HCV co-infected patients participating in a non-targeted emergency department HIV/HCV screening program.

Study Objective: Recent studies demonstrate that the emergency department (ED) can play a critical role in Hepatitis C screening and linking care for those who test positive. Along with other public health initiatives, ED HCV screening programs help reduce community HCV burden. Historically, HIV/HCV co-infected patients have had poorer rates of linkage to care, treatment initiation and treatment completion for HCV than HCV mono-infected patients have. We sought to compare the rates of linkage to care between HCV mono-infected and HIV co-infected patients who were screened for HCV and HIV as part of a non-targeted ED HCV/HIV screening program.

Methods: Retrospective review of prospectively collected program evaluation data collected between June 6, 2018 and June 5 2019.  Eligible patients had to be 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV and HIV testing.  Socio-demographic variables, HIV and HCV status and linkage to care outcomes were abstracted from the program-screening database. Successful linkage to care was defined as attending at least one outpatient appointment with an HCV care provider.  Descriptive statistics (measures of central tendency and dispersion) were computed to characterize the data. Comparisons of groups (HCV mono-infected vs. HIV/HCV co-infected) were compared using Chi-square.

Results: Of the 427 patients found to have active HCV infection (VL+) during the screening period, 41 (9.6%) had unknown HIV status and were excluded from analysis. Of the 386 patients with known HIV status, 56 (13%) were found be HCV/HIV co-infected. HIV/HCV co-infected patients had a mean age was 51.  The majority of HIV/HCV co-infected patients were male (70%), African American (25%) and had public insurance (64.2%). Successful linkage to care was achieved in 37.5% of HIV/HCV co-infected patients. HCV mono-infected patients had a mean age was 51. The majority of HCV mono-infected patients identified as male (78%) and white (24.4%). Most had public insurance (58.7%).  Successful linkage to care was achieved in 31.8% of HCV mono-infected patients.  A total of 49 patients, (4 with HIV/HCV co-infection and 45 with HCV mono-infection) were lost to follow up. There were no statistically significant differences in demographics, insurance status, or rates of linkage to care between HCV mono-infected and HIV/HCV co-infected patients.  

Conclusion: Non-targeted HCV screening in the ED identified a large number of patients with active HCV infection, of which a significant portion were co-infected with HIV. There were no significant differences in age, gender, race, ethnicity or insurance status between HCV mono-infected and HIV/HCV co-infected groups. Contrary to prior studies, there were also no differences in linkage to care rates between these two groups.  Further investigation is required to determine if there are significant differences in HCV treatment initiation and sustained viral response (SVR) between HCV mono-infected and HIV/HCV co-infected individuals.

Ethan COWAN (NY, USA), Joseph HARDARDT, Samantha BRANDSPIEGEL, Erick EITING, Yvette CALDERON
00:00 - 00:00 #23575 - Characteristics of healthcare workers in a Covid-19 area in an Emergency Department based on their job position.
Characteristics of healthcare workers in a Covid-19 area in an Emergency Department based on their job position.

Background:

The Emergency departments are one of the areas where the Covid-19 pandemic is being treated. In the analysed emergency department, a specific zone for the care and treatment of suspected Covid-19 infected patients has been created.  That zone works with personal protection equipment that can affect the professional performance but also are essential to avoid contagion.

Aims:

To Know the characteristics of the healthcare workers who works in the Covid zone of an Emergency department based on their job position.

Material and Methods:

A study of volunteer health care staff who worked in  a Covid-19 zone in an Emergency Department during the month of April 2020 was carried out. The following variables were analyzed: Age, age group: 18-40 years, >40 years.  gender, job title: doctor, nurse, assistant, years of experience: <6, 6-15, >15 years;  temporality: permanent or temporary;  previous pathologies: hypertension, mellitus diabetes (MD), headache, previous respiratory disease, hypothyroidism, physical state: survey: sedentary, active, athlete; training perception, fear of working in the COVID zone: low, medium, high.  Descriptive analysis of the sample according to job position, comparison of qualitative variables, by  Chi-square and ANOVA for quantitative variables.  Software: SPSS 24.0;  p <0.05.

Results: 

N: 107; Median age: 39.6 (10.0) years; GE: 22-40: 54 (50.5%), >40: 53 (49.5%); Female: 82 (76.6%); Fixed: 34 (31.8%); Medical: 27 (25.2%), Nursing: 51: 47.7%, Assistant: 29: 27.1%. Previous pathologies: Hypertension: 2.8%, MD: 0.9%, Hypothyroidism: 8.4%, previous respiratory disease (asthma, copd, allergy): 9.3%, headache: 3.7%. Sedentary: 44.9%, active: 36.4%, sports: 18.7%; Training: low: 15.0%; medium: 33.6%, high: 51.4%. Analysis by position: Mean age: physician: 41.1 (7.3) years, nursing: 35.9 (9.5), ATSD: 44.9 (10.8) (p<0.001): GE: >40: physician: 51.9%, nursing: 37.3%, assistant: 69.0% (p<0.05); Sex: female: physician: 77. 8%, Nursing: 70.6%, assistant: 86.2% (p>0.05); Marital status: married: physician: 51.9%, Nursing: 33.3%, assistant: 37.9% (p>0.05); Employment status: Fixed: physician: 40.7%, Nursing: 25.5%, assistant: 34.5% (p>0.05). Physical condition (sedentary, active, sportsman): physician (37.0%, 37.0%, 25.9%), nursing (47.1%, 35.3%, 17.6%), assistant: (44.9%, 36.4%, 18.7%) (p>0.05): Training received (low, medium, high): doctor: (7.4%, 37.0%, 55.6%), nursing (17.6%, 33.3%, 49.0%), assistant (17.2%, 31.0%, 51.7%) (p>0.05), Level of fear of entering (low, medium, high): doctor (59.3%, 18.5%, 22.2%), nursing: (33.3%, 25.5%, 41.2%), assistant (37.9%, 20.7%, 41.4%) (p>0.05). 

Discussion: 

Healthcare workers entering the covid area are generally young, without previous pathologies and preferably of the female gender. The nursing group is significantly younger than the rest. It is observed that the medical personnel are the ones who show more training and less fear of work, which may indicate that training makes the level of fear of this type of work decrease, although no statistically significant differences have been observed with the other groups of professionals analysed.

Dr Raul LOPEZ IZQUIERDO (Valladolid, Spain), Laura FADRIQUE MILLAN, Virginia CARBAJOSA RODRIGUEZ, Francisco MARTÍN RODRIGUEZ, Miguel Angel CASTRO VILLAMOR, Vanesa HERNANDEZ BRUNO, Ana Maria GONZALEZ FERNANDEZ, Escudero Cuadrillero CARLOS, Irene ALONSO FERRADAL, Portillo Rubiales RAQUEL, Esther DURA BALLESTER, Candelas GALINDO APARICIO, Villahoz Cancho ISABEL, Delgado Alonso LORENA, Inmaculada GARCÍA RUPEREZ, Irene CEBRIAN RUIZ, Ruiz Merino ROCIO
00:00 - 00:00 #23700 - Characteristics of the patients assessed in an Emergency department (ED) with minor head injury diagnosis following the implementation of a new protocol.
Characteristics of the patients assessed in an Emergency department (ED) with minor head injury diagnosis following the implementation of a new protocol.

BACKGOUND:

Head traumas are a frequent reason for attendance at an ED, Up to 75 % of  traumas  are classified as minor, more likely associated with elderly people. Between 1 and 4 % of patients, presenting minor head trauma will develop life threatening brain injury. The biggest challenge is to ensure correct management and diagnosis. Head CT scan is the first line diagnosis tool. The purpose of the study is to analyse head trauma patients characteristics in a first level Hospital following the implementation of a new protocol.

 

METHODS:

A Descriptive observational study was performed including patients assessed in Urduliz Hospital ED after setting up a head trauma protocol during the period of 2 months, between the 25th of January and 15th of March. To adequate the CT performing criteria, a Head injury form was used. All patients included had a final discharge diagnosis of head injury. The epidemiological variability, the number of head CT scans, radiological findings, second CT scan performance and the final discharge destiny were studied. Statistical data analysis was made with SPSS Statistics Version 22.0.

 

 

RESULTS:

The sample included 147 subjects examined and diagnosed with head Injury. 51.7 % were women and 48.3 % men. The average age was 67 with a range between 14 to 98 years. 50% of the patients were older 75 years, 14.3 % had dementia history, associated with an increased risk of falling. Drug and alcohol abuse was present in 7.5 % of the cases. Regarding the use of bleeding risk drugs 24.5 % of the patients were on antiplatelet, 11.6 % were on anticoagulants and only 8.2 % were taking direct acting anticoagulants. 96.6 % of patients on bleeding risk drugs were older than 65 years.

The new protocol was followed in 98.6 % of the cases, but the form to adequate indication to undergo a CT scan was not fulfilled in 95.2 % of the cases.

123 patients underwent a head CT scan, 83.7 % (103) were reported with no abnormal findings, nine with intracranial haematoma and one was reported as subarachnoid haematoma.

Following the new protocol 25 patients with normal first CT underwent a second CT scan, in 80 %, the second examination was normal, 4 cases were reported with intracranial haematoma and one case as subarachnoid haematoma.

The average hospital admission was of 25 hours. 90.5 % of the patients were discharged home with a written discharge advice; only six patients were referred to a neurosurgical department.

 

DISCUSSION AND CONSLUSIONES:

The implementation of a new protocol has shown a decrease in the risk of discharging patients with potentially serious brain injuries.

In addition in patients on anticoagulant drugs, the second head CT scan has been reported with abnormal findings in up to 20 % of cases.

On the other hand, the protocol has increase the hospital admission time and the number of CT scan performed.

Carbajo Azabal SILVIA (SPAIN, Spain), Barrenechea Barruetabeña IKER, Garaizar Bilbao IRATI, Luco Gonzalez GUILLERMO, Ibarlucea Gorospe GARAZI
00:00 - 00:00 #23656 - Chest ultrasound in covid19 era: a retrospective analysis of forty-three patients evaluated from april 1st to april 25th at civico hospital in lugano, switzerland.
Chest ultrasound in covid19 era: a retrospective analysis of forty-three patients evaluated from april 1st to april 25th at civico hospital in lugano, switzerland.

Since the beginning of COVID19 pandemia, scientific societies reviewed the useful role of Chest Ultrasound (US) in patients with interstitial pneumonia from COVID19 1. In the Emergency Department (ED) of Civico Hospital in Lugano (TI, CH) US has been employing as a first bed-side step of chest imaging in suspected COVID19 patients. Our aim was to evaluate chest US images and CT results in patients with high suspicion of COVID19 and to assess the clinical outcome of patient discharge from ED after US evaluation. We analysed also the time of staying in the ED, as a secondary outcome. We performed a retrospective observational analysis of first consecutive 43 patients, considered suspected for COVID19, evaluated in a military tent of the ED of Civico Hospital during 25 days of COVID19 Pandemia. Forty-three consecutive non severe ill patients, 19 males and 24 females, 20 to 89 years old, evaluated in the ED for suspected COVID19 between01.04.2020 to 25.04.2020, underwent a chest US, performed by a skilled emergency physician. Patients data and vital signs and were registered by a nurse at a first triage tent. Chest US images were available in a hard-copy form and results were reported assigning a score calculated on numbers of areas interested and type of abnormality. Tomography results were registered and evaluated using CORAD-S system of examination. Average age of patients was 49,6 years; all 43 patients underwent a chest US examination: 28 (65%) patients had a completely normal US with 0, while 15 (34%) patients presented abnormalities at US. Among the 19 patients (44%) who underwent a chest CT  11 (25,5% of total) resulted CORADS 1 and, among them 8 (72%) presented positive US. We found no patients with a CORADS 2 score; 3 patients were CORADS 3 (6,9%) and, among them, we found 2 patients (66%) with US abnormalities. No patients received a CORADS 4 score. Five Patients received CORADS 5 (11,6%) score and among them all (100%) presented US abnormalities. No patients were found to have a CORAD 6 score. The average time in ED was 3 hours: 02h10m for US vs 04h04m for US+CT. Six patients presented a P/F < 40 KPa at arrival: all had US (100%) 2 patients (33,3%) were discharged without readmission and 4 (66,6%) patients were admitted to a non-intensive ward. Conclusions: as in recent studies, in our experience we found that US is comparable to CT especially for the high grade of abnormalities, reduces the time of staying in ED, thus reducing exposure of patients and workers to viral infection. Use of US appears safe since we had a very low rate of re-admission for patients who were discharged according to US results and without respiratory impairment. Limits are the retrospective structure of the study and the small number of patients. Anyway, this first analysis is a starting small study useful for further investigation of a possible role of simple algorithms to discharge or admit of patients with COVID19 evaluated in EDs. Ethic: not needed. Informed consent obtained.

Premila KAMLER, Sibilla Anna Teresa SALVADEO (Lugano, Switzerland), Carlo MAINO, Marco PANZERI, Greta Jeanne CATTANEO, Enrico Carlo ZUCCONI, Claudio CARNEVALE, Marco MARANDO, Emanuela ZAMPROGNO
00:00 - 00:00 #23612 - Comparison of R-CAT and conventional method for EKG interpretation in medical student.
Comparison of R-CAT and conventional method for EKG interpretation in medical student.

Background: Acute myocardial infarction (AMIis a major cause of death worldwide. 12-Lead electrocardiogram (ECG) is an important tool for AMI diagnosis. However, the accuracy of ECG interpretation depends on experience. Rapid-Cardiac Analysis Tool (R-CAT) is a new device that assists healthcare providers to interpret an ECG. This study aimed to compare the accuracy between using R-CAT and conventional interpretation method among medical students.

Method: A randomised experimental study was conducted on 40 participants, including 6thyear medical students and residents in emergency medicine. Participants had to interpret six ECG questions by using R-CAT and conventional method randomly. The outcome parameters included the total correct scores and total time.

Results: The mean score for ST-elevation myocardial infarction (STEMI) and non-STEMI ECG interpretation was higher in R-CAT: 2.75 ± 1.25 vs 2.00 ± 1.03 of 5 (p-value 0.045) and 2.80 ± 1.40 vs 2.2 ± 1.25 of 5 (p-value 0.072), respectively. Moreover, the use of R-CAT can help medical students to correctly interpret an ECG, similar to emergency medicine residents who performed diagnosis by conventional method (9.2 ± 2.45 and 9.80 ± 2.94 of 10, respectively; p-value 0.567).

Conclusion: R-CAT can help medical students to correctly interpret the ECG of patients with suspected AMI, similar to emergency medicine residents.

Jirayoot PATCHKRUA (-, Thailand), Supreeya PRASAD ADHIKARI, Paijit BUNTA, Chaiyaporn YUKSEN, Chetsadakon JENPANITPONG, Kasamon ARAMVANITCH
00:00 - 00:00 #22884 - Comparison of the early sepsis indicator, monocyte distribution width to procalcitonin and c-reactive protein in detection of sepsis-2 or sepsis-3 in the emergency department.
Comparison of the early sepsis indicator, monocyte distribution width to procalcitonin and c-reactive protein in detection of sepsis-2 or sepsis-3 in the emergency department.

Background: The variation in the size distribution of monocytes, referred to as Monocyte Distribution Width (MDW), is a new biomarker that aids in the early detection of sepsis and is available on a routine blood cell count with differential (CBC-DIFF). MDW’s performance in the Emergency Department (ED) has already been reported in two North American studies. The objective of this study was to evaluate MDW in a European population and compare MDW to PCT, CRP. We also sought to determine if MDW, when combined with clinical parameters such as SIRS or qSOFA improves the early detection of sepsis in the ED. 

Methods: An IRB-approved observational cohort study, funded by Beckman Coulter, was carried out in France and Spain between August 2018-June 2019 to assess MDW’s ability to detect the development of sepsis in consecutive adult patients presenting to the ED who have a CBC-DIFF ordered. Whole blood venous samples collected in K3EDTA were tested on the Beckman Coulter UniCel DxH900 hematology analyzer. Each patient had blood drawn concurrently for MDW, PCT and CRP. Demographic data, SIRS, qSOFA, SOFA, imaging, microbiological testing and treatments were collected and patients followed up through 72-hours after ED admission or discharge. The study endpoint was the diagnosis of sepsis-2 or sepsis-3 determined by 2 independent emergency physicians, blinded to MDW results. Discordant cases were arbitrated by a third physician.

Results: 1517 patients were enrolled (837 men and 680 women, average age 61 ±18 years) sepsis was diagnosed in 260 (17%), 197 SIRS, 241 infections and 819 controls according to sepsis-2 criteria. The areas under the ROC curve (AUC) and [ 95% confidence interval ] for the diagnosis of sepsis-2 were 0.81 [0.78-0.84], 0.78 [0.75-0.81], 0.85 [0.83-0.87] and 0.86 [0.84-0.89] for MDW, PCT, CRP, and MDW combined with white blood cell count (WBC), respectively. For sepsis-3 the biomarker performance was 0.82 [0.79-0.85], 0.84 [0.81-0.87], and 0.85 [0.82-0.87] for MDW, PCT, CRP, respectively. The statistical cut-off for MDW was 21.5 for K3EDTA. Inclusion of MDW with SIRS or qSOFA during the initial evaluation in the ED enhanced the odds of sepsis detection by 7- fold for sepsis-2 and 8- fold for sepsis-3.

Discussion: This large European study confirms the clinical performance of MDW coupled with leukocytes as an early biomarker of sepsis in the emergency room. MDW’s performance is comparable to that of PCT and CRP but superior to both biomarkers when combined with WBC. MDW +WBC are readily available on a routine CBC-DIFF, unlike PCT and CRP that are ordered only if the physician has a high index of clinical suspicion of sepsis. MDW +WBC has the advantage of being one of the first parameters tested at the time of ED admission, and when elevated may alert for potential sepsis even in situations of low clinical probability.

Conclusion: This study confirms the potential clinical utility of MDW as an early indicator of sepsis in the emergency room.  Combined with components of SIRS and qSOFA, MDW significantly improves the post-test probability of detecting sepsis among ED patients.

Marta CANCELLA DE ABREU, Julie PERNET, Neus ROBERT, Cristian MORALES, Pere TUDELA, Laetitia VELLY, Gemma ROCAMORA, Adrià MENDOZA, Iris CASTRO, Diana CAREAGA, Mohamad HASAN, Liliana TEJIDOR, Hausfater PIERRE (Paris)
00:00 - 00:00 #22745 - Comparison of the efficiency of oral airway and nasal airway inserted in the oral airway during mask ventilation.
Comparison of the efficiency of oral airway and nasal airway inserted in the oral airway during mask ventilation.

Backgrounds

The purpose of this study was to investigate the efficiency of nasal airway inserted in the oral airway (ON airway) in securing the airway patency during mask ventilation.

Methods

 Fifty eight patients undergoing general anesthesia were randomly assigned to either oral airway group (group O) or ON airway group (group N). In both group, 2 mg/kg of propofol was infused intravenously and mask ventilation was performed in the sniffing position without head extension or jaw thrust. The patients were ventilated with a volume-controlled ventilator with O2 flow of 10 l/min, tidal volume of 10 ml/kg (IBW), and respiratory rate of 10 /min. Before the start of mask ventilation, airway was placed in the oral cavity. Oral airway was used in group O and ON airway was used in group N. Peak inspiratory pressure (PIP), tidal volume and EtCO2 were compared between the two groups. The location of airway tip was graded by fiberoptic bronchoscope as; 0: airway obstructed by tongue, 1: epiglottis visible, 2: airway touches epiglottis tip, 3: airway passes beyond epiglottis tip.

Results

 Compared with group O, group N significantly decreased the PIP (25.0 [18.0 – 29.0] vs. 18.0 [16.0 – 19.0], P < 0.001, Group O and N, respectively) and increased tidal volume and EtCO2 during mask. In the bronchoscopic findings, airway obstruction was more frequent in group N. (P< 0.001).

Conclusions

Compared with oral airway, nasal airway inserted in the oral airway facilitates the mask ventilation by promoting the patency of airway.

Sung Hoon CHUNG (Seoul, Korea, Republic of), Seongjoo PARK
00:00 - 00:00 #23172 - Compliance of Greek emergency departments with the European Society for Emergency Medicine Guidelines for end of life care.
Compliance of Greek emergency departments with the European Society for Emergency Medicine Guidelines for end of life care.

Introduction: The concept of end of life (EoL) care, which is care offered to patients during the end of their lives, includes a combination of medical, psychological, social, emotional and spiritual care, both for the patient and those close to him. Compared to previous decades, it is more common nowadays for patients with acute diseases capable of producing death, or patients with the progression of a terminal illness, to visit an Emergency Department (ED) for care close to their EoL. EuSEM has recognized the importance of this issue by developing specific guidelines for EoL care in the ED. It is important to understand the current weaknesses of Greek EDs in EoL care in order to organize appropriate and more humane healthcare services. Purpose: The purpose of this study was to evaluate the compliance of Greek EDs with EUSEM EoL care guidelines. Methods: A questionnaire with 43 questions, based on the EUSEM guidelines on EoL care, was sent to either the head physician or the head nurse of all Greek hospitals with independent EDs. Pediatric, psychiatric, and other special hospitals were excluded. Results: 50 out of the 84 eligible hospitals responded to the survey (60% of all Greek hospitals, >70% population coverage). Only 18% of EDs reported having formal communication instructions for the staff regarding EoL issues and 22% reported having some form training in announcing a patient’s death. Although 80% of EDs reported that their physicians were able to identify EoL patients and in 72% discussions for advanced care-planning is performed, in less than 20% these discussions are formally recorded and in less than 30% “Do Not Attempt Resuscitation” (DNAR) decisions are documented. Around 60% of the EDs reported discharging patients with a care plan to die at their home and written discharge instructions. In more than 80% of the EDs a senior physician is responsible for EoL issues, EoL decisions (if nobody else can take them for the patient) and the announcement of a death. However, only in a minority of Greek EDs family is included in EoL decisions or discussions. 78% of EDs reported ignorance for the legal status of DNAR orders in Greece and only 14% had access to legal advice. In most cases (92%) DNAR is decided by a senior specialist, but in 34% CPR is continued if the family insists, and in 22%  CPR is performed even against expressed patient wishes. 38% provide palliative care but only 12% have an organized checklist. Most Greek EDs do not have special rooms for the family during EoL situations but 66% have facilities for their cultural and spiritual needs. Finally, in 62% of EDs, staff members are encouraged to talk about EoL events. Conclusion : Greek EDs should further improve EoL care. Our study shows that there are several improvements that could be made in communication training, discussion/decision recording,
DNAR management, dedicated use of space and support of ED staff on legal and stress-related EoL issues.

Emmanouil - Fanourios MARKAKIS, Panagiotis AGOURIDAKIS, Dr George NOTAS (HERAKLION, Greece)
00:00 - 00:00 #22613 - Developing Trauma Induced Cioagulopathy Increases The Necessity For Blood Tranfusions.
Developing Trauma Induced Cioagulopathy Increases The Necessity For Blood Tranfusions.

Premise and goals: Severe trauma is the first cause of death worldwide for patients of age 40 or less. About 30% of severe trauma patients presents with trauma induced coagulopathy at arrival to the E.D. About 40% of trauma deaths are related to bleeding, a quarter of which seems preventable.  Goal of this study is to determine if patients presenting with trauma induced coagulopathy (TIC) were also more frequently affected by greater hemodynamic instability.

Methods: We conducted a monocenter prospective observational study involving all patients affected by severe trauma in the Emergency Department of the
Fondazione Policlinico IRCCS S. Matteo in Pavia in 12 consecutive months: from the 1st of January 2018 to the 31st December 2018. All patients registered as affected by severe trauma in our Emergency Department have been enrolled. Inclusion criteria are to satisfy at least one of the pathognomonic classification criteria for severe trauma as defined by the American College of Surgeons, Advanced Trauma Life Support (ATLS@) and approved by regional deliberation...

These criteria are distinguished in anatomical and mechanism of injury criteria.
We considered patients affected by coagulopathy if positive for at least two altered biochemical values traditionally used to study coagulopathy. Patient undergoing an anticoagulant therapy have been excluded.

Results:  We evaluated 503 patients in total.
204 were affected by trauma induced coagulopathy (80% of which males) with an average age of 44 years and peak incidence between 55 and 65 years old.
299 were not affected by coagulopathy (68% of which males) with an average age of 43 years and peak incidence between 25 and 35 years old.
In our population, the incidence of hemodynamic instability as defined by the American College of Surgeons is greater in the population with coagulopathy than without (15% vs 8%).
Patients affected by TIC have greater need for blood transfusion compared to patients without TIC. This is valid both for blood transfusions at arrival to the ED (8.5% vs 3.3%; p=0.028) and for blood transfusions required during hospital stay (11.32% vs 4%; p=0.016).

Conclusions:
Among patients presenting with severe trauma within the same population (400.000 people ca.) in an Italian Trauma Center of II level, those who at arrival in ED have already developed trauma induced coagulopathy have a greater necessity for blood transfusions in comparison with the patients without TIC.

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Sarah MACEDONIO, Mirko BELLIATO, Lorenzo COBIANCHI, Alessandra LIVRAGHI, Cesare PEROTTI, Federica MANZONI, Giorgio Antonio IOTTI, Maria Antonietta BRESSAN
00:00 - 00:00 #23122 - Difference of blood-brain barrier injury of rats with various thoracic cage size after cardiopulmonary resuscitation.
Difference of blood-brain barrier injury of rats with various thoracic cage size after cardiopulmonary resuscitation.

Background

Cardiac arrest (CA) is a serious threat to human life. After returning of spontaneous circulation (ROSC), the ischemia-reperfusion injury (IRI) damages the blood-brain barrier (BBB), increases its permeability and loses brain protection function, which is an important cause of subsequent brain injury. Exploring factors affecting the BBB injury after ROSC has important research value. The thoracic cage is the direct position of external chest compression, the thoracic cage size variation may affect the blood pressure during CPR according to the “thorax pump” theory. Therefore, we established a CA-CPR-ROSC rat model to explore the variation between the thoracic cage size and the severity of BBB injury. We hypothesized that the variation of thoracic cage size may cause difference of MAP level during CA-CPR-ROSC and the inflammation level after ROSC, and thus cause differences in BBB damage.

Methods

Forty male Sprague-Dawley rats were performed chest computed tomography scans to compare the thoracic cage size variation. At the 4th intercostal level, the following thoracic cage size parameters were measured in chest CT images using Mimics 17.0 software: internal transverse diameter, internal anteroposterior diameter and cross-sectional area. After CT scanning, twenty small thoracic cage male SD rats were randomly divided into small thoracic cage sham group and small thoracic cage CPR group. Similarly, 20 large thoracic cage male SD rats were randomly divided into the large thoracic cage sham group and large thoracic cage CPR group. We established CA-CPR-ROSC rat model and used fluorescence to compare the degree of EB exudation in the cerebral cortex, immunofluorescence and Western blot to compare the changes of tight junction protein occludin and claudin-5 expression; Furthermore, we compared the mean blood pressure (MAP) difference during CA-CPR-ROSC, IL-1β and TNF-α expression, microglia activation and M1 type polarization.

Results

Compared with the small thoracic cage CPR group, the EB exudation in the large thoracic cage CPR group was significantly higher (p<0.05). Compared with the small thoracic cage CPR group, the occludin and claudin-5 expression in large thoracic cage CPR group were significantly reduced (p<0.05). Repeated variance analysis found that compared with the small thoracic cage CPR group, the MAP in the large thoracic cage CPR group was significantly reduced during CA-CPR-ROSC (p<0.05). Compared with small thoracic cage CPR group, the IL-1β and TNF-α expression in the large thoracic cage CPR group were higher. The microglia activation and M1 type polarization in the large thoracic cage CPR group were higher than small thoracic cage CPR group.

Conclusion

Rats with large thoracic cage size had more severe BBB damage after ROSC. The reasons might be related to lower MAP level during CPR, more inflammatory factors and release higher levels of microglial activation, M1-type polarization, in the cerebral cortex of rats with large thoracic cage size.

Pr Yu CAO (Chengdu, China), Junzhao LIU, Dr Sheng YE, Yarong HE, Di HAO, Peng YAO
00:00 - 00:00 #22089 - Do high risk head injury patients get appropriate cervical spine imaging? An Emergency Department Audit.
Do high risk head injury patients get appropriate cervical spine imaging? An Emergency Department Audit.

Background

Cervical spine injuries (CSIs) are amongst the most devastating injuries following trauma. Several patient groups are at high risk of having missed CSIs. These include elderly patients where CSIs can occur with lower energy trauma and patients with a decreased conscious level (whether that be due to confusion, dementia or intoxication) where clinical assessment of CSIs is more difficult.

National and local hospital guidelines state that adults with indications for a CT head should also have a CT C-spine (CT CSP) if they fulfil one of the following criteria:

1)     age >65

2)     confused or GCS < 15    

The objective of this audit was to assess whether patients are being appropriately sent for CT CSP according to this guideline.

 

Methods

A list of all adults (age >18) sent for CT Head in the Norfolk and Norwich Emergency Department from December 2018 - February 2019 (3 months) was obtained. Radiology requests were viewed for all patients and all head injury patients identified. 

For these head injury radiology requests were examined to see if the patient was >65 years of age, confused (as defined by a note of confusion / intoxication in the description) or GCS <15. CT CSP requests were noted. The audit standard was 100%.

Interventions included discussion at clinical governance, teaching for Emergency Department clinicians and discussion with radiology that for ambulatory patients C-spine protection was not needed for transfer to radiology unless there was a strong suspicion of CSI.

Re-auditing took place between June 2019 – Aug 2019.

Results

During Dec 2018 – Feb 2019 47% of patients meeting the above criteria were sent for CT CSP (272/514 patients). This improved to 59% in the re-audit period June 2019 – Aug 2019 (58/99 patients).

 

Discussion & Conclusions

Our interventions improved the overall proportion of at-risk head injury patients that received appropriate c-spine imaging. However overall concordance with the guidelines was still fairly low on re-audit. 

One recurring scenario where elderly patients were routinely not sent for CT CSP involved patients taking anticoagulants. In such patients, who are alert and orientated with no clinical suspicion of C-spine injury but meet the NICE criteria for CT Head based on use of blood thinning medication, it is an interesting question to ask whether incorporating CT CSP is appropriate.

The incidence of acute C-spine pathology in this subgroup of head injury patients was 3% overall which lower than the reported incidence of CSI in trauma (4 to 8%). This suggests that the department is detecting fewer C-spine injuries, further emphasising the importance of high clinical suspicion and low threshold for CT scanning in high risk groups. 

Overall, we show that appropriate C-spine imaging is important and may be under-utilised. Education, discussion at departmental meetings and appropriate agreements between EDs and radiology can improve decisions to image the C-Spine in head injury patients.

Nipuna SENARATNE (Cambridge, United Kingdom), Rebecca FERRIS
00:00 - 00:00 #23662 - Do patients with stroke benefit from installing stroke specific triage system in emergency department?
Do patients with stroke benefit from installing stroke specific triage system in emergency department?

Introduction: Stroke, which can be hemorrhagic or non-hemorrhagic and either benign and self-limited or life-threatening, needs appropriate diagnosis and treatment in the emergency department (ED).  The aim of this study was to compare the delivery time of primary care for patients with signs and symptoms of stroke before and after applying stroke-specific triage system (SSTS) in ED. 

Methods: Medical records were reviewed of twenty-one patients (group I) with a chief complaint related to stroke who referred to ED between April and August 2019 (before installing SSTS) and twenty-three patients (group II) with the same chief complaints who referred between September and December 2019 (after installing SSTS). The time between patients’ arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and Brain CT scan and ECG performance was compared between the two groups. 

Results: Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p=0.33). Door to Brain CT scan performance, Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post stroke-specific triage installing period than previously (p<0.01). Door to first visit by a physician was not statistically different in the two study periods (p=0.421). 

Conclusion: It is likely that patients with signs and symptoms of stroke who referred to ED benefit from installing SSTS in terms of performing some physician and nursing care including Brain CT Scan and ECG performance, starting cardiac monitoring, and IV insertion.

Seyed Hossein HOSSEINI DAVARANI (Tehran, Islamic Republic of Iran), Amir NEJATI, Houman HOSSEIN NEJAD
00:00 - 00:00 #23454 - Does a proforma perfect paediatric elbow radiograph reports? Original research report.
Does a proforma perfect paediatric elbow radiograph reports? Original research report.

Does a proforma perfect paediatric elbow radiograph reports? Original research report.

L Dann1, 2, C Blackburn1,4, M J Barrett1,3, 4 , T Beattie2

1.      Children’s Health Ireland at Crumlin, Dublin

2.      University of Edinburgh

3.      National Children’s Research Centre, Dublin

4.      School of Medicine, University College Dublin

 

Background:

Interpretation of elbow x-rays is an important and frequently encountered area of injury assessment and may result in lifelong morbidity if fractures are missed. Studies have demonstrated that there are more errors when interpreting paediatric images and when the interpretation is performed “out of hours”. Studies have also demonstrated that inaccuracies in x-ray interpretation by trainee doctors may result in mismanaged fractures. We introduced a structured proforma to improve trainee reporting of elbow radiographs and aimed to evaluate its effect on the quality of reporting amongst trainee doctors.

 

Outcome Measure:

To evaluate the effect of a structured proforma on quality of reporting of elbow x-rays amongst trainee doctors.

 

Methods:

Trainee doctors in a paediatric emergency department of a tertiary paediatric hospital were recruited for this evaluative study. Over a single educational session trainees reported 10 elbow x-rays. These were reported initially on blank paper and then using the structured elbow proforma (same images, different order).

Reports were scored from 0-10 with 10 being the highest achievable score. Marks were awarded for mentioning important aspects of the image, e.g. presence/absence of fat pads. Descriptive statistics were used where relevant and appropriate. Paired t-tests were used to compare pre and post proforma results. A p-value of <0.05 was selected as statistically significant.

 

Results:

Thirteen trainees took part in the study. The median report scores before and after the proforma were 1 (IQR 0, 2) and 10 (IQR 10, 10). Overall there was a median increase in reporting score of 8 (IQR 8, 8). [T value 44, and two-tailed p <0.001].

 

Discussion:

Many hospitals use proformas for various tasks but there is limited published evidence of their use in x-ray interpretation.  The authors propose this study is the first to analyse the impact of a proforma on reporting of paediatric elbow radiographs. Results demonstrate that the use of a structured proforma greatly improves the quality of reporting. Results were consistent among all grades and types of trainees. Strengths of this study are its originality, variety of trainees recruited and the consistent results demonstrated. Limitations are the small participant numbers and the single site nature of the study undertaken.

 

Conclusion:

This study demonstrates that the introduction of a structured proforma for reporting paediatric elbow radiographs can significantly improve the quality of radiograph reporting among all levels of trainees. A larger multi-centre study is required to validate the results of this study and assess if it has an impact on fracture identification.

 

Lisa DANN (Dublin, Ireland), Carol BLACKBURN, Michael BARRETT, Tom BEATTIE
00:00 - 00:00 #23204 - Does the emergency department have a role in penicillin allergy de-labelling in children?
Does the emergency department have a role in penicillin allergy de-labelling in children?

Background

Penicillin allergy (PenA) is the most common reported drug allergy in the emergency department (ED). Given that most antibiotic allergy labels acquired in childhood are carried into adulthood, the over labelling is an absolute drawback resulting in undesirable health care risks, antibiotic resistance, and increased costs. There is growing data to support key historical features to accurately stratify patients into low and risk groups which is crucial in application of direct oral challenge. The aim of this study was to evaluate the knowledge of reported PenA and impact of PenA labels amongst prescribers in the children’s ED. It was hypothesized that while over 70% will correctly identify the high-risk symptoms of PenA, much less than 50% may be aware that oral drug challenge is the gold standard for PenA diagnosis.

 

Methods

This was a cross-sectional anonymised survey of prescribers working in the children’s ED of Leicester Royal Infirmary, UK. The paper-based survey was distributed to prescribers over a 2-week period in December 2019. The survey comprised several sections: characteristics of respondents, clinical vignette, knowledge of high- and low-risk symptoms of PenA, questions on allergy focused history, and knowledge of impact of PenA labels. Primary outcome measure was knowledge of low- and high-risk symptoms of reported PenA.

 

Results

Sixty-two questionnaires were returned from clinical grades ranging from consultants to foundation year doctors, as well as advanced nurse practitioners. Over 90% of respondents correctly identified signs and symptoms suggestive of anaphylaxis as high-risk symptoms. Knowledge of onset of rash over an hour of penicillin ingestion as a low-risk symptom was significantly associated with penicillin antibiotic prescription (21/37 versus 16/37; p-value 0.01). While less than 50% of respondents would clarify the time interval between ingestion and symptoms, a lower proportion (38%) would verify if allergy was confirmed by testing. Eighty seven percent agreed that PenA was over diagnosed but 66% agreed that it can lead to antibiotic resistance. Only 33% agreed that confirmation of PenA was by oral challenge.

 

Conclusion

There is low rate of allergy focused history in addition to deficient understanding of low-risk symptoms of PenA amongst prescribers in the ED. Allergy education in conjunction with an algorithm to safely de-label children with such symptoms in the ED will contribute immensely to antimicrobial stewardship. The survey demonstrated willingness of prescribers to adopt such decision tool.

 

Kene MADUEMEM (Birmingham, United Kingdom), Umair KHAN
00:00 - 00:00 #23429 - Emergency Airway Management. A multi-site survey of Irish Emergency Departments.
Emergency Airway Management. A multi-site survey of Irish Emergency Departments.

Introduction

Emergency Airway Management (EAM) has now become an integral part of core and advanced specialty training in Emergency Medicine (EM) in Ireland. Although EAM is frequently performed in Emergency Departments (EDs) today, there is a paucity of literature on airway management in Irish settings. The aim of this study was to assess the resources and infrastructure in Irish EDs in relation to EAM. This study was facilitated by the Irish Trainee Emergency Research Network (ITERN) as part of an overall airway project entitled the National Emergency Resuscitation and Airway Audit (NERAA).

 

Methods

ITERN recruited sites in Ireland to participate in NERAA. A survey was then distributed to each site and data including site demographics, airway equipment, airway trolley and airway training data was extrapolated. The survey data was handled by Google forms.

 

Results

A total of 15 ED sites were enrolled. 86.7% of these sites (n=13) were designated as training site for the National Emergency Medicine Training Program. Eighty six percent of sites (n=13) had a rapid sequence induction (RSI) checklist in the ED. Seventy three percent(n=11) had a video laryngoscope available in ED and all sites had one available in their respective hospitals. The brand of ventilator in each ED varied with 40.0% of sites (n=6) using an Oxylog, 20.0% (n=3) using a LTV, 13.3% (n=2) Draeger, 13.3% (n=2) Hamilton, 6.7% (n=1) Phillips and 6.7% (n=1) Maquet. Regarding simulation training in ED, 33.3% (n=5) sites have ran RSI or airway simulations in the past 6 months. 80.0% (n=12) of sites had a difficult airway trolley in ED with 91.7% (n=11) having a checklist for contents and 50% (n=6) of these trolleys having a difficult airway algorithm to refer to.

 

Conclusion

This site-survey is the first multi-site analysis of airway management in Irish EDs. This study also highlights the feasibility of a research network to perform multi-site data collection and in this case, provide a summary of current airway practices in Irish EDs. This study shows that there is variation between EDs regarding brand of ventilator used and that the majority of EDs have an RSI checklist and a video laryngoscope in the ED. Particular points of focus relating to EM training are that only one third of sites have ran an RSI or airway simulation in the past 6 months. The findings of this study could provide a vector for the development of national standard for EAM in Ireland.

Itern COLLABORATORS (Dublin, Ireland)
00:00 - 00:00 #22869 - Emergency department registered nurses’perceived disaster preparedness as assessed using Benner’s model of clinical competence.
Emergency department registered nurses’perceived disaster preparedness as assessed using Benner’s model of clinical competence.

BACKGROUND

 

Major incidents (MI) occur with little or no warning. During an MI emergency department (ED) registered nurses (RN) are among the first to receive, assess and treat patients. Emergency department RNs’ emergency operating plan (EOP) competencies are crucial in effectively mitigating somatic and psychological afflictions that patients may present to the ED. While previous research has indicated the ED nurses’ disaster competencies are low, little is known about the current state of emergency department registered nurses’ EOP competencies in Sweden.

 

AIM

 

To assess emergency department registered nurses’ EOP competencies.

 

METHOD

 

Study design: A cross sectional online survey was conducted during a six-week period between January and February 2019. Purposive criterion sampling method was utilized in recruiting participants.

Participants:  All registered nurses’ (n ≈ 370) employed at six participating emergency departments in the region of Stockholm, Sweden were included.

A total of 100 questionnaires were completed (response rate = 28%). Competencies were rated utilizing a five-point Likert scale based on Benner’s competence model of clinical competence.

The primary outcome variables are five competencies concerning ED EOPs. 1. Content of the EOP 2. Areas of responsibilities. 3. Differences between decision making processes in the Incident Command System for a major incident vs. non-emergency situations. 4. Hospital levels of preparedness and its significance. 5. Decontamination procedures according to the EOP. Predictor variables included ED experience, education levels and frequency of training.

Data was analyzed using descriptive statistics generating means, standard deviations, frequency counts, and percentages. Kendall’s tau b assessed correlation. A p value of <0.05 was considered significant.

 

RESULTS

 

The majority of nurses (77%) had at least 3-5 years of nursing experience. The overall mean of five combined competencies was 2.95 or just below “competent” on Benner's model. The primary outcome variables mean ranged from 2.77- 3.27. (1. “contents of the EOP” (mean 2.77 SD 1.25.), 2: “Areas of responsibilities” (mean 2.8 SD 1,23), 3. “decision making processes in the Incident Command System” (mean 2.88 SD 1.21), 4. “Hospital levels of preparedness and its significance.” (mean 3.27 SD 1.18) and 5. “Decontamination procedures according to the EOP” (mean 3.03 SD 1.29).  The strongest positive correlation (r=0,502 p= 0.01) was between clinical experience and self-assessed levels of competency (range mean 1.2 to 3.80 ,< 1 year and > 20 years respectively).

 

CONCLUSION

 

Nurses’ overall competency concerning disaster preparedness is slightly lower than “competent” according to Benner’s competence estimation model. The majority of nurses disaster experience. Accruing actual MI experience may be elusive due to the rarity of MI.  The results of this study however indicate that nurses’ disaster competencies may be inadequate. However, despite relatively low levels of competency, these results indicate that ED RNs may increase their disaster medicine competencies through clinical experience, training and education.  Due to the relatively small sample size, the results may be generalized in similar settings with caution.

Jason MURPHY (Stockholm, Sweden), Sophia MAGNUSSON, Tove RINGQVIST, Monica RADESTAD, Lisa KURLAND, Anders RUTER
00:00 - 00:00 #22917 - EPICANCER – Cancer patients presenting to the emergency departments in France: a prospective nationwide study.
EPICANCER – Cancer patients presenting to the emergency departments in France: a prospective nationwide study.

Introduction

Cancer patients are likely to use emergency care resources for medical complications that may occur during or after cancer therapy. We aimed to estimate the prevalence of cancer patients that present to the Emergency Departments (EDs) in France, report their chief complaint, describe their characteristics and identify predictors of 30-day mortality.

 

Methods Cross-sectional, prospective study during three consecutive days in 138 EDs. All consecutive patients with cancer were included. Estimation of cancer patients’ prevalence, identification of main reasons to attend ED, and predictors of 30-day mortality for patients admitted to the hospital after ED presentation. The study was approved by the Institutional Review Board of the French Speaking society for respiratory medicine – Société de Pneumologie de Langue Française (number CEPRO 2017-038).

 

Results A total of 1,380 cancer patients were included. Prevalence was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal symptoms (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of the cases, of whom 13.4% died at day 30. Variables independently associated with higher in-hospital mortality at day 30 were male gender [OR, 1.67; 95% CI, 1.07-2.60], poor performance status [OR, 3.40; 95% CI, 2.15-5.38], solid [OR, 3.15; 95% CI, 1.30-7.61] or uncontrolled malignancy [OR, 2.25; 95% CI, 1.35-3.73], ED attendance for a neurological disorder [OR, 2.13; 95% CI, 1.23-3.69], high shock-index [OR, 1.76; 95% CI, 1.02-3.05] or oxygen therapy [OR, 2.55; 95% CI, 1.61-4.05].

 

Conclusion

This large prospective nationwide study about cancer patients seeking emergency care, representing 3% of total ED attendance, shows high need for hospitalization and case fatality. Malignancy and general health status both play a major role in patient outcomes, and should be taken into account by emergency physicians in adapting the level of care.

Olivier PEYRONY (Paris), Jean-Paul FONTAINE, Sébastien BEAUNE, Abdo KHOURY, Jennifer TRUCHOT, Frédéric BALEN, Rishad VALLY, Jacques SCHMITT, Kasarra BEN HAMMOUDA, Mélanie ROUSSEL, Céline BORZYMOWSKI, Cécile VALLOT, Véronique SANH, Elie AZOULAY, Sylvie CHEVRET
00:00 - 00:00 #23139 - Epidemiology of Benzodiazepine Exposures using the National Poison Data System.
Epidemiology of Benzodiazepine Exposures using the National Poison Data System.

Background: The rate of annual healthcare visits involving prescription benzodiazepines increased from 3.8% to 7.4% between 2003 and 2015 in the United States. Benzodiazepines-related overdose mortality has risen sharply, from 0.6 per 100,000 adults in 1999 to 4.4 per 100,000 adults in 2016. Approximately 30% of overdoses involving opioids also involve benzodiazepines. The objective of the study was to describe the epidemiology of benzodiazepines exposures using a national poison center (PC) database.

Methods: The National Poison Data System (NPDS) was queried for human exposures to benzodiazepines from 2013 to 2019 using the specified generic code identifiers. We descriptively assessed the relevant demographic and clinical characteristics. Reports from acute care hospitals and emergency departments (ACHs) were analyzed as a sub-group. Trends in benzodiazepines frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2013) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 490,572 human exposures to benzodiazepines reported to the PCs from 2013 to 2019, with the annual calls decreasing from 75,108 to 58,377 during the study. Polysubstance exposures accounted for 73.5% of benzodiazepines exposures. Of the total benzodiazepines calls, the proportion of calls from ACHs increased from 63.7% to 69.3% during the study period. Multiple substance exposures accounted for 70.6% of the calls involving benzodiazepines from ACHs. Approximately 23.1% of the patients reporting benzodiazepine exposures were admitted to the critical care unit (CCU), while 12.3% of the patients were treated and released. Residence was the most common site of exposure (93.6%) and 75.8% cases were en-route to the hospital when the PC was notified. Among the patients, 61.4% were females, with the majority of benzodiazepine exposures occurring between the ages of 20-29 years (18.6%). Suspected suicide (60.6%) was the most commonly reported reason for exposure. The proportion of such cases was higher in reports from ACHs (74.1%). Compared to the overall sample, suspected suicide intent was significantly lower among single substance benzodiazepine exposures (60.6% vs 47.6%). Major effects were seen in 6% of cases and the case fatality rate was 0.5%. Notably, there was an approximately 54% decrease in the number of annual deaths reported to the PCs. The most frequently co-occurring substances associated with the cases were alcoholic beverages (15.9%) and antipsychotics (8.8%). Tachycardia (15.2%) and respiratory depression (5.5%) were commonly observed clinical effects. During the study period, the frequency of benzodiazepine exposures decreased by 22.3% (95% CI: -21.5%, -23.2%; p<0.001), and the rate of benzodiazepine exposures decreased by 20.8% (95% CI: -16.7%, -24.7%; p=0.03).

Conclusions:  Benzodiazepine exposures decreased during the study period. However, a larger percentage of the calls were from healthcare facilities suggesting higher healthcare utilization related to benzodiazepines. Although the deaths declined, this fails to capture patients who died before reaching medical care, and the true death rate should be compared with other sources, such as medical examiner data.  Benzodiazepines have also been increasingly associated with suicidal ideation, which was the most common reason for exposure in our sample.

Saumitra REGE (Charlottesville, VA, USA), Jennifer ROSS, Heather A. BOREK, Dr Christopher HOLSTEGE
00:00 - 00:00 #23182 - Epidemiology of Severe Oxycodone Exposures Reported to the U.S. Poison Centers, 2008 – 2018.
Epidemiology of Severe Oxycodone Exposures Reported to the U.S. Poison Centers, 2008 – 2018.

Background: Drug overdoses are a leading cause of unintentional injury-associated death in the United States (U.S.) with 68,577 fatalities in 2018. Between 2016 and 2017, oxycodone comprised of approximately 18.8% of all prescribed opioids in the United States. There were 182,748 visits to emergency departments (ED) related to oxycodone products in 2010. This study aims to examine the national trends in oxycodone exposures reported to the U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for human oxycodone exposures from 2008 to 2018. Severe outcomes (SO) were cases that resulted in major medical outcomes or death. We descriptively assessed the relevant demographic and clinical characteristics. Trends in oxycodone frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2008) were reported with the corresponding 95% confidence intervals (95% CI). We developed a predictive logistic regression model to identify important predictors of severe outcomes with oxycodone exposures.

Results: There were 183,058 oxycodone exposures reported to the PCs from 2008 to 2018, with the calls decreasing from 16,644 to 12,982 during the study period. Among the overall oxycodone calls, the proportion of calls from acute care hospitals and EDs increased from 40% to 58.8% from 2008 to 2018. Multiple substance exposures accounted for 54.5% of the overall oxycodone calls. Cases between ages 30 – 49 years were more common among the SO group (41.3%) as compared to the non-SO group (39.3%). Suspected suicides (55.8% vs 34.4%) and intentional abuse (19.1% vs 11.1%) were more frequent in the SO group. Additional co-occurring opioids were reported in 14% of the SO cases and 7% of non-SO cases. Benzodiazepines were the most frequently reported non-opioid co-occurring substance in both groups. The frequency of oxycodone exposures decreased by 22.5% (95% CI: -24.2%, -20.8%; p<0.001), and the rate of oxycodone exposures decreased by 14.1% (95% CI: -22.6%, -5.3%; p=0.009). In multivariable-adjusted analyses, the risk of SO with oxycodone exposures was significantly associated with older age with cases between 50-59 years (Adjusted Odds Ratios [AOR]: 2.15, 95% CI: 2.00 – 2.31) demonstrating significantly increased odds of such outcomes. Males were 10% more likely to have a SO as a result of an opioid exposure (AOR: 1.10, 95% CI: 1.06 – 1.15). Suspected suicide (AOR: 2.22, 95% CI: 2.10 – 2.36) and abuse (AOR: 3.21, 95% CI: 2.98 – 3.35) were strong predictors of SO (Reference: Unintentional Reasons). Exposures to more than three substances (AOR: 3.16, 95% CI: 2.95 – 3.39) and involvement of parenteral route of administration (AOR: 2.53, 95% CI: 2.09 – 3.06) significantly increased the risk of a serious outcome in oxycodone exposures.

Conclusions: PC data demonstrated a decreasing trend of oxycodone exposures, which may in part be attributed to the reformulation of this medication with abuse‐deterrent properties in 2010. However, the increase in the calls from the acute-care hospitals and EDs indicates a higher risk of such exposures which may be mediated by several clinical and demographic factors. 

Saumitra REGE (Charlottesville, VA, USA), Patki TEJAL, Dr Christopher HOLSTEGE
00:00 - 00:00 #23078 - Establishing a novel high-fidelity simulation model for effective teaching and training of ultrasound guided Fascia Iliaca Compartment Block, and a quantitative survey to assess its impact.
Establishing a novel high-fidelity simulation model for effective teaching and training of ultrasound guided Fascia Iliaca Compartment Block, and a quantitative survey to assess its impact.

Background: Ultrasound guided fascia iliaca compartment block has increasingly been utilised in the emergency and anaesthetic departments in the initial symptom control of patients presenting with neck of femur fractures. High-fidelity simulation models that are reproducible and sustainable for effective teaching and training have been lacking. The aim of this study was to establish a model, and to assess its educational and training impact on local and regional courses.

Methods: Three fresh chicken breasts were stacked on top of each other, with the middle breast placed inside a plastic sandwich bag representing the fascia lata and iliaca on either side. Two modelling balloons were filled with water, and a stripped electric wire was prepared, to represent femoral vessels and nerve respectively. These were placed accordingly between the chickens and bag. The whole model was sutured using size one suture and a cling film were applied around it all before placing the completed assembly on a tray. Ultrasound linear probe was used to ensure the correct sonographic representation of the structures. This represented a high-fidelity simulation model which was used at the Leeds Teaching Hospital Trusts Emergency Medicine Junior Clinical Fellows teachings, and the Yorkshire and Humber deanery Acute Common Care Stem (ACCS) Trainees mandatory regional introductory ultrasound courses. All trainees had the opportunity to perform the procedures in real time with injecting water as a representation for local anaesthetic agent with direct supervision. At the end the candidates were asked to anonymously complete an electronic feedback form with four questions. These were confidence level pre- and post-simulation, the tactile feedback of the model, and the sonographic representation of the structures. The scale was 1-5, with 1 indicating lowest and 5 highest. The median and interquartile range of for each response was calculated as the primary outcome.

Result: All the 65 participants completed the questionnaire. The median improvement levels were 2 (IQR 2), 4 (IQR 1), 4 (IQR 1),4 (IQR 1) for confidence level pre- and post-simulation, the tactile feedback of the model, and the sonographic representation of the structures, respectively.

Discussion and Conclusion: We have shown that it is feasible to establish a reproducible and sustainable high-fidelity simulation model for effective teaching and training of ultrasound guided Fascia Iliaca Compartment Block. This could improve the confidence level of trainees in performing the procedure in clinical practice with less supervision level.

Nick MANI (Leeds, United Kingdom), Mohit ARORA
00:00 - 00:00 #22494 - Estimation of no-flow duration and survival in patients with an initial shockable rhythm after out-of-hospital cardiac arrest.
Estimation of no-flow duration and survival in patients with an initial shockable rhythm after out-of-hospital cardiac arrest.

Background: In patients with unwitnessed out-of-hospital cardiac arrest (OHCA), the actual no-flow duration (the time with no organ perfusion) is unclear. However, when these patients have a shockable rhythm as an initial recorded rhythm, the no-flow duration may be relatively short as compared with other initial rhythms, and some patients can obtain a good functional outcome after OHCA.

Purpose: The purpose of the present study was to estimate the no-flow duration and to determine the relationship between no-flow duration and neurologically intact survival in patients with an initial shockable rhythm after OHCA.

Methods: We reviewed 82,464 patients with OHCA (aged ≥18 years, non-traumatic, witnessed, and without any bystander interventions) who were included in the All-Japan Utstein-style registry from 2013 to 2017. The study end point was 1-month neurologically intact survival (Cerebral Performance Category scale 1 or 2). No-flow duration was defined as the time from emergency call to emergency medical services (EMS) arrival at the patient site.

Results: The rate of 1-month neurologically intact survival in the patients with an initial shockable rhythm (n = 10,384, 12.6% of overall patients) was 16.5% (1718/10,384). No-flow duration was significantly and inversely associated with 1-month neurologically intact survival (adjusted odds ratios for 1-minute increments: 0.85, 95% confidence interval: 0.84–0.86). The proportion of patients with a shockable rhythm to the overall patients (y, %) had a high correlational relationship with no-flow duration (x, min), depicted by y = 21.0 - 0.95 × x, R² = 0.935. In this analytical model, the number of patients with shockable rhythm reached null at 22 minutes of no-flow duration. The no-flow durations, beyond which the chance for initial shockable rhythm diminished to <10%, <5%, and <1%, were 12, 13, and 17 minutes, respectively. The rate of neurologically intact survival in the patients with shockable rhythm (y, %) and no-flow duration (x, min) were also found to have a strong correlation, depicted by y = 0.16 × x² - 5.12 × x + 45.0, R² = 0.907. The no-flow durations, beyond which the chance for 1-month neurologically intact survival diminished to <10%, <5%, and <1%, were 10, 11, and 15 minutes, respectively.

Conclusions: In OHCA patients without any bystander interventions before EMS personnel arrival, when a shockable rhythm is recorded by EMS personnel as an initial rhythm, the no-flow duration after cardiac arrest is highly likely to be

Yoshikazu GOTO (Kanazawa, Japan), Akira FUNADA, Tetsuo MAEDA, Hirofumi OKADA, Yumiko GOTO
00:00 - 00:00 #22764 - Evaluation of cutoff values in acute paracetamol overdose following the guideline of the United Kingdom.
Evaluation of cutoff values in acute paracetamol overdose following the guideline of the United Kingdom.

Background

 Risk prediction for hepatotoxicity in acute paracetamol (AAP) overdose has been dependent on the classic nomogram, but the emergency medical centers in some developing countries do not have laboratory resources to provide drug level in time. The Medicines and Healthcare Products Regulatory Agency (MHRA) and the Commission on Human Medicines in the United Kingdom revised the guideline in 2012, which recommends that the treatment threshold for the patients who ingested more than 75 mg/kg in 24 hours, should be lowered to ‘100-treatment line’ without risk stratification of hepatotoxicity. The primary aim of the study is to evaluate the optimal AAP dose that could be used as cutoff value for N-acetyl cyteine(NAC) treatment in the environment that AAP serum level cannot be provided in time.

Methods

 Data were collected retrospectively from two emergency departments(ED) that more than 60,000 patients visit annually, between 2010 and 2017. Inclusion criteria were acute single AAP intoxication with dose ≥75 mg/kg, visited ED in 15 hours after overdose and over 14-year old. The trend of change in the frequency of toxic level with increasing dose was determined by chi square test for trend. The sensitivity, specificity of 100, 125, 150 and 175 mg/kg for the level above 100-line were calculated.

Results

 A total of 196 patients were enrolled in the primary analysis. 187 patients (95.4 %) were intentional self-harm attempt and the majority of the patients, 166 (84.7 %) were overdosed with extended-releasing tablets, compound preparation with caffeine, decongestants, antihistamines or cough suppressants, or medications of other different classes.  56 of 196 subjects (28.6 %) showed AAP toxic serum level on the first test. 6 subgroups were created by 25 mg/kg of reported dose per weight. There was positive trend that the higher intoxicated dose per weight, the higher the frequency of toxic concentration in the first AAP serum level test (chi square test for trend, chi square=7.63, p-value = 0.0057). The sensitivities for predicting serum APAP toxic levels over the 100-treatment line at, ingestion doses of 100, 125, 150, and 175 mg/kg were 85.7%, 76.8%, 69.6%, and 60.7%, respectively, while the corresponding negative predictive values were 77.1%, 80.3%, 80.5%, and 79.4%, respectively.

Discussion & Conclusions

 Following the revised UK guideline that lowered the treatment line to 100 mcg/ml on 4-hour and 15 mcg/ml on 15-hour without risk stratification of hepatotoxicity, for the patients over 14-year old, visited ED in 15 hours after acute single AAP overdose, the dose over 100 mg/kg can be safely suggested as a toxic exposure for NAC antidote therapy.

Hyun Ho JEONG, Kyungman CHA, Kyoung Ho CHOI, Byung Hak SO (Suwon, Korea, Republic of)
00:00 - 00:00 #22980 - Evaluation of stroke diagnostics using FAST algorithm in emergency medicine.
Evaluation of stroke diagnostics using FAST algorithm in emergency medicine.

Background:
The early diagnosis of stroke remains a challenge in emergency medicine. In Germany, the FAST (F=Face; A=Arms; S=Speech and T=Time) algorithm – a structured assessment of several focal neurological deficits – is currently used to determine its probability. However, a systematic validation and evaluation of the algorithm’s performance is lacking. We thus aimed to evaluate the predictive value of the FAST algorithm in a retrospective analysis.

Methods:
The presented retrospective mono-center validation- study included all patients who were admitted to the emergency department of a single neurology and university hospital in the county Marburg-Biedenkopf with the suspected diagnosis stroke within less than 6 hours'' over a eighteen-month period (from July 2018 to December 2019) for analysis. Results of preclinical examination, performed by mainly non-physician staff, were retrieved from emergency service protocols.

Immediately after arrival at the emergency room of the university hospital Marburg, neurological examinations have been investigated by medical doctors of the department for neurology, following well established standards of neurological examination of the National Institutes of Health Stroke Scale (NIHSS). In case of suspicion of a stroke after clinical examination, diagnose was validated by MRI (magnetic resonance imaging). Sensitivity, specificity, and positive likelihood ratio were calculated as recommended by Wilson and Brown.

Results:
1278 patients were included in our analysis and have been examined in emergency room.
The pre-clinical investigation of the FAST algorithm predicted a stroke with a sensitivity of 64% (95% CI 60-69%, n = 1126) and a specificity of 51% (95% CI 48-55%, n = 1126). The positive likelihood ratio was 1.347.  Within the clinical setting, sensitivity increased to 77% (95% CI 73-80%, n = 1278) with a specificity of 60% (95% CI 56-63%, n = 1278) and a likelihood ratio of 1.945.

Discussion & Conclusion:
While modest specificity might be tolerable in the present setting, the FAST-algorithm provided low sensitivity for correct detection of a stroke within the analysed cohort. Although, applying the same algorithm, results of pre-clinical examination considerably diverged from results of the clinical examination, following NIHSS. Since cerebral ischemic stroke is a time-sensitive diagnosis, the development of highly sensitive tests is crucially necessary to enable rapid interventions of treatment. Therefore, an advanced algorithm is desperately needed for further improvement of stroke-diagnostics in emergency medicine.

Christian Jonas REULING (Marburg, Germany), Felix BERNHARD, Erich WRANZE-BIELEFELD, Andreas JERRENTRUP, Lars TIMMERMANN, Susanne BETZ
00:00 - 00:00 #22960 - Experiences with and attitudes towards screening for geriatric vulnerability among older Emergency Department patients: a qualitative study.
Experiences with and attitudes towards screening for geriatric vulnerability among older Emergency Department patients: a qualitative study.

Background
Screening tools assessing geriatric vulnerability in older Emergency Department (ED) patients are seldom put to use in routine care. This study explores experiences with and attitudes towards routine screening for geriatric vulnerability among older ED patients.
Methods
Individual face-to-face semi-structured interviews were conducted at home in older patients (
70 years) within one month after they completed the ‘Acutely Presenting Older Patient’ (APOP) screener at the ED of Leiden University Medical Center. Purposive convenience sampling was used to select a heterogeneous sample of participants regarding age, disease severity and APOP-screening result. Interviews were audio recorded and transcribed verbatim. Transcriptions were analyzed inductively using thematic analysis with Atlas.ti software.

(Preliminary) results
After 13 interviews (6 men, 7 women, median age 81 years), data saturation was reached. Most participants considered the vulnerability screening to be part of routine care and could not remember the particular screening questions, except for the cognition test. Their overall attitude towards the concept of screening was positive. Participants believed that vulnerability screening could help to identify the patient as a whole and adapt care to the patient’s needs, which they considered important for all patients, regardless of age. Participants who did not consider themselves to be vulnerable, did not personally experience an added value of the screening but they did believed in the added value for others.

Conclusion

From an ED-patients’ perspective, screening for geriatric vulnerability was experienced as a part of routine ED care and was considered to be of added value for optimal ED care.

Laura BLOMAARD (Leiden, The Netherlands), Mareline OLTHOF, Yvette MEULEMAN, Jacobijn GUSSEKLOO, Simon MOOIJAART, Bas DE GROOT
00:00 - 00:00 #22786 - Factors Associated with 24 Hours Revisit to Emergency Room for Elderly Patients.
Factors Associated with 24 Hours Revisit to Emergency Room for Elderly Patients.

Background / problem / goal

The proportion of the elderly population in Taiwan is rapidly increasing. It is estimated that by 2026, the elderly population will exceed 20%, becoming a "super-aged society." The emergency medical resources used by the elderly over 65 years are much higher than those of other age groups. The purpose of this study is to explore the factors related to "unplanned return visits" of elderly emergency patients at a medical center in the south to improve emergency congestion.

 

Method

Retrospective data analysis was adopted, according to the data of emergency patient registration. (1) Return visits to the emergency department within 24 hours; (2) Return visits to the emergency department of the elderly over 65 years; perform descriptive statistical analysis, and the study period is 2019.05.01 ~ 2019.10 .31

 

Results

During the study period, 872 people returned to the emergency department within 24 hours, accounting for 1.9% of the total number of emergency departments, and there were 248 elderly people over 65, accounting for 28.4% of all age groups.

The chief complaint reasons for the second visit were different,

 28.6%, the condition worsening or complications occurring, 1.6%, the symptoms not improving, 23%, the recurrence of symptoms, 44.8%, patient requested by physician to return, 1.2%, 2 reasons were not entered, 0.8%.

In terms of in-patient department , the hospitalization rate for returning to the emergency department within 24 hours was 47.6%, among which 95.8% was the most in internal medicine, and 4.2% in the other (surgical, trauma, and ophthalmology).

Out-of-hospital order for returning to the emergency department, AAD (Against Advice Discharge), 11.7%, MBD (May Be Discharged), 40.7%, and hospitalization, 47.6%. After discharge from the hospital, the study subjects used only 1.6% of home-based care, and  6.5% of care institutions, 4.4% of elderly care centers, and 2% of nursing homes.

 

Conclusion

"Unexpected return to the emergency department in the short term" will cause the hospital emergency department quality to decline,

Among them, the majority of people over 65 years old (28.4%).

Analysis of the reasons is that: due to physical deterioration and cognitive decline in the elderly, the elderly have many companion diseases, which leads to patients often seeing emergency doctors. In terms of mental state, Because the elderly are old, living alone and lacking social support, they often have depression. which is also one of the reasons for returning to the clinic..

Nursing staff can communicate with patients and their families during the emergency department to understand their physical, psychological and social support status. When the patient is discharged from the emergency department for the first time, giving good health care instructions may reduce unnecessary return visits.

Regarding the lack of integration of long-term care institutions, if the local community can implement a cross-field cooperative service model by the nurses, combined with physicians, physiotherapists, and social workers, nurses will perform care, disease education, and nursing home visits, call care, resource links and referrals will bring more benefits and implement localized care services.

Pao-Ling LIU (Kaohsiung, Taiwan, China)
00:00 - 00:00 #22030 - Factors associated with pulmonary complications after chest contusion with rib fracture among elderly.
Factors associated with pulmonary complications after chest contusion with rib fracture among elderly.

Background

Chest blunt trauma is an important contributor to morbidity and mortality, which affect 15% of total blunt trauma patients. This is particularly injurious among the elderly, who display a predilection for the development of pneumonia and other pulmonary complications.
On 2016, Western Trauma Association recommend all chest trauma patient aged older than 65 years old with more than 2 ribs fractures need to be admitted to intensive care unit for strictly monitor. But this recommendation is only based on their experience and institutional protocol lack of proper documented
evidence support.
The aim of this study is to identify the factors and mechanism associated with pulmonary complication after chest contusion with rib fracture among
elderly. The results would help emergency physician to identify high risk patient at emergency department.

Material and method

This was a retrospective study conducted from January 2016 to October 2018 at a level I trauma center in Taiwan. MacKay Memorial hospital is a medical center. All patients aged ≥65 years with blunt chest trauma with rib fracture between 1 January 2016 and 31 October 2018 were identified. We excluded patients with any of the following : (1) admission for medical disease, (2) any body region except chest with AIS score >3 (3) no rib fracture reviewed by radiologist (3) out hospital cardiac arrest.

Results

We identified rib fracture(s) in 315 cases among 2,765 elderly presented to emergency department with thoracic trauma. There were 159 males (50.5%) and 156 females (49.5%) ranging in age between 65 and 98 years (mean . years). Two-third of patients injuried outdoor(215/315, 68.3%). The leading cause of the trauma was falls (N=174, 55.2%) and following as riding motorbike(N=103, 20.3%) and pedestrian hit by vehicle(N=18, 5.7%). One-third of elderly with rib fracture (N=107, 34.0%) had at least one of pulmonary complication including hemothorax(N=78, 24.8%), pneumothorax(N=37, 11.8%), pneumonia(N=24, 7.7%), Respiratory failure(N=16, 5.1%) and flail chest (N=4, 1.3%).
Pulmonary complications increase as the numbers of rib fractures increased. There were moderate correlation between the numbers of rib fractures and pulmonary complication rates (r = 0.550, p <0.001). Besides, there were no significant correlation between admission days and the numbers of rib fracture (r = 0.007, p =0.929). 
We also identified patients with more than two ribs fracture or more than two comorbidities had significant increase pulmonary complications : ≥3 ribs fracture(aOR :13.935, 95% CI: 6.916-28.079,) and more than two comorbidities (aOR : 3.317, 95% CI: 1.579-6.964)

Chihchun HUANG (Taipei, Taiwan, China)
00:00 - 00:00 #22892 - Forgoing Health Care Under Universal Health Insurance: The case of France.
Forgoing Health Care Under Universal Health Insurance: The case of France.

Objectives : We investigate the reliability of a survey question on forgone health care services for financial reasons, based on analysis of actual healthcare use over the three-year period preceding response to the question. We compare the actual use of different health services (general practitioner, emergency department, hospital admission) by patients who report having forgone health care to those who do not.

 

Methods : Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

 

Results : Compared to controls, forgoing care participants had lower odds of consulting GPs (OR=0.83 ; 95% CI=0.73, 0.93), especially specialists outside hospitals (gynecologists : 0.74 (0.69, 0.78) ; dermatologists : 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75) ;  higher odds of ED visits (OR=1.25 ; 95% CI=1.19, 1.31) ;  and no difference in hospital admissions (OR=1.02 ; 95% CI=0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

Conclusion : The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). With lower odds of consulting physicians in CBAC and higher odds of visiting ED, our study supports the notion that EDs might partially replace GPs and specialists for populations that forgo seeking health care in CBAC. While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons. 

Anne-Laure FERAL-PIERSSENS (Paris), Claire RIVES-LANGE, Joane MATTA, Victor RODWIN, Marcel GOLDBERG, Philippe JUVIN, Marie ZINS, Claire CARETTE, Sebastien CZERNICHOW
00:00 - 00:00 #23330 - Glue vs Suture – A prospective controlled study on long term outcome of facial lacerations in children.
Glue vs Suture – A prospective controlled study on long term outcome of facial lacerations in children.

Background:
Although skin adhesives have been used for decades to treat pediatric skin lacerations, uncertainty remains about long-term results and complications. Objective of this study was therefore to evaluate early and long-term complications, aesthetic results, costs, duration of treatment, and quality of life (QoL) for tissue adhesive versus suture to repair facial lacerations in children.

 

Methods:

Design: Prospective, controlled, single-blind study
Setting: Emergency Department of the University Children’s Hospital Zurich, a tertiary hospital with a census of more than 42’000 annual emergency visits
Participants: Children aged 0-16 years presenting with a laceration on the face between 07/2017 and 08/2018
Main Outcomes and Measures: Outcomes were assessed by five independent, blinded adult or pediatric plastic surgeons by means of photographs at 6-12 months using a modification of the validated Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS). Additionally, POSAS was performed at day 5-10 (early follow-up) and month 6-12 (late follow-up) by the patients or caregiver(s) and the physician. Complications and QoL were assessed by standardized measures.

Results:
367 patients were enrolled, of which 230 were included in the main analysis. 96 wounds were closed using tissue adhesives (group 1); 134 were sutured (group 2). Assessment by the independent observers revealed an improved mean modified overall POSAS score in group 1 in comparison to group 2 (of 2.1 ± 0.7 vs 2.5 ± 0.7; p< 0.001) and mean VSS score (1.2 ± 0.9 vs 1.6 ± 0.9; p< 0.001). At the early follow-up, dehiscence rate was 12.5% in group 1 and 3.7% in group 2 (p< 0.001). At the late follow-up, 1 dehiscence remained per group. Mild impairment of QoL was found at the early follow-up in both groups, with no impairment remaining at long-term follow-up. Mean duration of treatment was significantly lower in group 1 than in group 2 (6.3 ± 4.0 min vs. 11.6 ± 7.2 min; p< 0.001). Treatment costs were 33.5% lower in group 1.

Discussion and Conclusions:
Both modalities of wound closure yield favorable aesthetic results and lead to low rates of complications. Adhesives are more cost-effective and application is less time-consuming and, therefore, tissue adhesives offer considerable advantages when used appropriately.

Sonja FONTANA (Zurich, Switzerland), Clemens Maria SCHIESTL, Markus Andreas LANDOLT, Georg STAUBLI, Sara VON SALIS, Kathrin NEUHAUS, Julia ELROD
00:00 - 00:00 #23086 - Health outcome goals and healthcare preferences reported by older people with frailty and emergency care needs.
Health outcome goals and healthcare preferences reported by older people with frailty and emergency care needs.

Background

Health outcome goals are the results which individuals seek from healthcare. These may not be limited to health state and could incorporate holistic themes including function, mood, social roles, and quality of life. Healthcare preferences here are the processes and procedures which individuals would accept in order to achieve their health outcome goals.

 

Our recent systematic review thematically classified older people’s health outcome goals as efficient and comprehensive care, sensitivity towards vulnerability, and person-centred and informed care. We stressed the importance of understanding individual perceptions.

 

People living with frailty are known to have poorer outcomes from even short hospital stays. They benefit from person-centred, goal-directed care over protocol-driven pathway approaches. A better understanding of their healthcare goals would enable best care to be initiated in emergency departments.

 

Methods

This qualitative study design is based on grounded theory. 35 older people (aged over 65) with frailty (clinical frailty score over 4) are being recruited using opportunistic sampling during their emergency department attendance at Leicester Royal Infirmary (a large teaching hospital with diverse multicultural catchment). People with cognitive and communication barriers such as dementia are included, with familiar caregivers assisting as consultees.

 

Semi-structured interviews are being audio-recorded in participants’ homes within one month of their acute care episode. Discussions focus on identifying the events and outcomes that participants wanted to take place during emergency care. Verbatim transcripts are being analysed contemporaneously using a blended approach based on constant comparison. Ideas expressed in the data are assigned codes, which are expanded and merged to yield theme categories.

 

Initial results

Data collection was paused due to the outbreak of COVID-19. Initial results showed a predominance of person-centred and holistic care themes among health outcome goals. ‘Management of symptoms’ was participants’ most common goal for emergency care. People often had pain and wanted to feel comfortable. Participants were often living with severe frailty and wanted their mobility to be assessed, with goals of recovering their functional baseline. Within the ‘information and understanding’ theme, while participants had confidence in healthcare professionals and were generally willing to “do as we are told to feel better”, they expected to undergo at least basic tests in order to receive a working diagnosis for their problem. People not only wanted to understand their illness, but also for explanations to be communicated to their relatives.

 

Participants reported healthcare preferences to include emergency department accessibility, cleanliness, and efficiency. People felt vulnerable and forgotten, both when in busy waiting rooms and on trolleys in closed cubicles. They wanted staff to be aware of their need for assisted feeding and toileting.

 

Discussion

Initial results showed older people with frailty to have some unique health outcome goals for emergency care. These should be assessed on an individual basis, and may show people to seek control of pain and maintenance of mobility in preference over cure of disease.

James VAN OPPEN (Leicester, United Kingdom), Simon CONROY
00:00 - 00:00 #22670 - Healthcare economic burden in the United States of atrial fibrillation patients treated with oral factor Xa inhibitors and hospitalized with a major bleed.
Healthcare economic burden in the United States of atrial fibrillation patients treated with oral factor Xa inhibitors and hospitalized with a major bleed.

Background: Oral factor Xa inhibitors (oFXaIs) are used as anticoagulation therapy to reduce stroke risk of patients with atrial fibrillation (AF). However, as anticoagulants, these medications are associated with increased bleeding risk.

Purpose: To examine the healthcare burden of AF patients treated with oFXaIs who were hospitalized in the U.S. with a major bleed (MB) with a breakdown by MB type.

Methods: Patients (≥18 years) treated with oFXaIs (rivaroxaban, apixaban, or edoxaban) who had an inpatient hospitalization with MB (January 1, 2015-April 30, 2018) were extracted from the MarketScan claims databases. The index date was defined as the first MB inpatient hospitalization. Patients were grouped into 3 study cohorts based on the type of MB: gastrointestinal (GI), intracranial hemorrhage (ICH), and other MB type. Healthcare resource utilization and costs were evaluated for index MB hospitalizations and during the 6-month period prior to the index event and a variable follow-up period of 1-12 months for the study cohorts. Multivariable regression analyses were conducted to examine the impact of having ICH or other MB type vs. GI MB on index event hospital length of stay and cost, as well as all-cause healthcare costs in the follow-up. The covariates in the regression analyses included age, gender, U.S. geographic region, payer type, Charlson Comorbidity Index score, CHA2DS2-VASc score, HAS-BLED score, select comorbidities, oFXaI type, and AF type. All costs were inflated to 2019 USD and annualized.

Results: Among the study population of AF patients treated with oFXaIs who had an MB hospitalization (N=7,577), 55.9% had GI MB (N=4,236; mean age: 76.8 years; 48% female), 9.9% had ICH (N=753; mean age: 77.9 years; 42% female), and 34.2% had other types of MB (N=2,588; mean age: 74.4 years; 39% female). For index GI MB, ICH, and other MB hospitalizations, unadjusted mean lengths of stay were 5.0, 6.8, and 5.5 days, respectively; mean costs were $26,901, $54,163, and $36,645, respectively. From the adjusted analyses, for index hospitalizations, patients with ICH vs. those with GI MB spent on average 1.6 more days in the hospital (p<0.001) and had an average of $15,630 higher hospitalization cost (p<0.001); patients with other types of MB vs. those with GI MB spent on average 0.6 more days in the hospital (p=0.001) and had an average of $5,859 higher hospitalization costs (p<0.001). During the follow-up period after the index hospitalization, all-cause inpatient, outpatient medical, and total healthcare (inpatient, outpatient medical, and outpatient pharmacy) costs per patient were $9,376 (p=0.019), $4,734 (p=0.008), and $14,037 (p<0.001), respectively higher for ICH patients vs. GI MB patients; they were $1,738 (p=0.350), $3,089 (p=0.003), and $5,208 (p=0.011), respectively higher for other MB patients vs. GI MB patients.

Conclusions: Among 7,577 AF patients treated with oFXaIs and hospitalized for MB in the U.S., GI MB was most prevalent. All 3 MB categories were associated with high hospitalization costs; however, in comparison to GI MB, ICH and other types of MB had higher average costs for index events and all-cause total healthcare costs during the time period following MB hospitalization.

Gregory FERMANN, Belinda LOVELACE (South San Francisco, USA), Mary CHRISTOPH, Melissa LINGOHR-SMITH, Jay LIN, Steven DEITELZWEIG
00:00 - 00:00 #22998 - HYPERGLYCAEMIA SECONDARY TO HYPOGLYCAEMIA.
HYPERGLYCAEMIA SECONDARY TO HYPOGLYCAEMIA.

BACKGROUND:

 

One of the most important therapeutic complication for the patients with diabetes mellitus (DM) is hypoglycaemia.

 

While administering the treatment, it is important to follow guidelines´ recommendations and protocols, since the overcorrection in the glucose level, can provoke metabolic alterations and a descompensatory process in the diabetes regulation.

 

OBJECTIVE:

 

To determine the rate of patients presenting hyperglycaemia subsequent to hypoglycaemia at the emergency department and to analyse the same rate according the type of diabetes and the previous treatment.

 

MATERIAL AND METHODS:

 

Observational descriptive and analytical exploratory study performed at the Emergency Department in La Ribera University Hospital. it has been studied patients with a diagnosis of hypoglycaemia at discharge during the months of March and July 2019.

The variables used were: sex, age, cause of hypoglycaemia, hypoglycaemia treatment and presence of subsequent hyperglycaemia (blood glucose at some time during admission after starting treatment greater than or equal to 180mg/dl).

 

RESULTS:

 

A total number of 93 pacients were studied. The 81,7% has Type II DM. The 21,7% has as basal treatment with non-insulinic hypoglycaemic drugs and insulin previous to the admission to the emergency department. Low-dietary intake of glucose was the main reason of hypoglycaemia (64,52%) followed by administering mistakes (9,68%) and bad control of the disease (8,60%). A 94,6% of the patients was treated with glucose saline (5-10%), a 90,3% of the patients was treated orally and  86% was prescribed with Glucosmon.

 

Subsequent hyperglycaemia was notice in 43% of the cases and it was slightly superior in patients with Type I DM (56,3% vs 41,3%) p= 0,373, oberserving no significant differences (p=0,652) while styding the presence of hyperglycaemia regarding the patient’s previous treatment: 45% of  hyperglycaemia was observed in the group of patients with a basal treatment with non-insulinic hypoglycaemic drugs, 48,6% in patients receiving insulin and 37,8% in patients treated with a combination treatment with the above mention drugs.

 

 

CONCLUSION:

 

The study found a high percentages of hyperglycaemia in the group of patients who visited the emergency department due to hypoglycaemia, which results give us an evidence of non-follow up correctly of the clinical recommendations and guidelines.

 

Ricardo MUÑOZ, María CUENCA (Alzira, Spain), Immaculada TORMOS, Asier BENGOECHEA, Luisa TARRASO, Luis MANCLÚS
00:00 - 00:00 #21810 - Impact of door-to-deployment time of venoarterial extracorporeal membrane oxygenation for out-of-hospital refractory cardiac arrest patients secondary to cardiovascular causes: A single-center, retrospective, observational study.
Impact of door-to-deployment time of venoarterial extracorporeal membrane oxygenation for out-of-hospital refractory cardiac arrest patients secondary to cardiovascular causes: A single-center, retrospective, observational study.

Background: Door-to-balloon time in patients with ST-elevation myocardial infarction is reported to be an independent predictor of the prognostic implication and was suggested to be included in current guidelines. However, the effect of door-to-deployment time (DTDT) of venoarterial extracorporeal membrane oxygenation (VA-ECMO) on patients with out-of-hospital cardiac arrest (OHCA) is unclear.

Purpose: This single-center, retrospective, observational study aimed to evaluate the effect of DTDT of VA-ECMO for mortality or neurological outcome of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiogenic OHCA.

Method & Result: This single-center, retrospective, observational study was conducted from January 2008 to April 2019. The primary endpoint was 1-month overall survival measured after ECMO initiation. Moreover, the secondary endpoint was 1-month survival with favorable neurological functions defined as having a cerebral performance category score of 1 or 2. A total of 3082 patients with OHCA were brought to our institution and 84 received ECPR. Of these, 51 consecutive adult patients with cardiogenic OHCA without sustained return of spontaneous circulation during transport were included in this analysis. Approximately 18 patients (18/51, 35.3%) survived after 1 month and were discharged. Among the survivors, 15 (15/18, 83.3%) were discharged with a favorable neurological outcome. The baseline characteristics between the survivors and non-survivors were not significantly different, except for the initial shockable rhythm [18/18 (100%) versus 28/33 (84.9%), P = 0.03]. There were no statistically significant differences between the median time from collapse to hospital arrival [31.0 min (IQR 25.0–31.0) versus 29.0 min (IQR 25.0–39.5), P = 0.53] and from call to hospital arrival [28.0 min (IQR 22.0–32.5) versus 27.0 min (IQR 23.3–34.5), P = 0.56]. The median DTDT of VA-ECMO was significantly shorter in survivors [13.0 min (IQR 11.5–18.3) versus 21.0 minutes (IQR 15.5–32.0), P = 0.01]. The Kaplan–Meier survival analysis showed that 1-month overall survival rate and survival rate with a favorable neurological outcome were significantly higher in the group with a DTDT ≦ 20 min (31 patients) than that with a DTDT > 20 minutes (20 patients), [11 patients (50.0%) versus 4 patients (19.0%), P < 0.01 and 11 patients (46.0%) versus 4 patients (14.0%), P = 0.01, respectively]. Using the Cox proportional hazards analysis, DTDT ≦ 20 minutes and bystander-witnessed significantly affected the overall survival rate at 1 month [adjusted hazard ratio (HR), 0.44; 95% confidence interval (CI), 0.20–0.95; and P = 0.03 and adjusted HR, 0.31; 95% CI, 0.13–0.74; and P < 0.01, respectively]. Regarding survival rate with a favorable neurological outcome, the result was relatively similar [adjusted HR, 0.46; 95% CI, 0.22–0.96; and P = 0.04 and adjusted HR, 0.37; 95% CI, 0.16–0.85; and P = 0.02, respectively].

Discussion & Conclusions:  Bystander-witnessed, bystander CPR and initial shockable rhythm are considered as favorable predictors of adult ECPR. However, there is still limited information about DTDT of VA ECMO in the previous studies. This study revealed that the DTDT of VA-ECMO is significantly associated with the 1-month mortality and neurological prognosis of patients with cardiogenic OHCA. However, further studies will be required to confirm these findings.

 

Hiromi MURANISHI (Osaka, Japan), Ryosuke ZUSHI, Yoshiki YAGI, Shunya KAWASAKI, Suguru TANAKA, Makiko FUKUDA, Hitoshi KOBATA
00:00 - 00:00 #22896 - Impact of the consultation of "e;internet tools"e; on the attendance of adult emergencies.
Impact of the consultation of "e;internet tools"e; on the attendance of adult emergencies.

INTRODUCTION

Over the years, emergency services have experienced a sharp increase in requests for consultations, contributing to the progressive saturation of these structures. At the same time, for several years now, there has been easier access to GAFAs (Google, Amazon, Facebook, Apple) allowing patients to have 24-hour access to medical information. To our knowledge, no French study has evaluated the impact and prevalence of consulting a website before admission to the emergency room.

The objective of our work is to assess the impact of a prior search for medical information on a website in patients presenting to an emergency department, as well as the relevance of consultation in the emergency department.

 

METHOD:

This is a pilot, observational, monocentric, prospective study carried out within the adult emergency department of a teaching hospital over the period from 11/03/2019 to 24/03/2019. Patients presenting to the emergency department on their own were included. An anonymized questionnaire was given to patients at the reception. (NCT03881839)

 

RESULTS:

Among the 462 patients included in our study, 14% of patients consulted the internet versus 86%, with 50.8% and 58.8% respectively of diagnoses qualifying the passage to the emergency room as "justified / relevant". Patients accessing the internet are more commonly between the ages of 18 and 24, have a higher level of education and have a mobile phone. These patients said they sought medical information several times a day, sometimes for symptoms that started less than 5 days ago. After multivariate analysis, the justified / relevant nature of the passage is less frequent in patients who consult the internet every day (OR = 0.48, CI 95%: 0.28-0.84, p = 0.01) and in those who consult medical information websites (OR = 0.51, 95% CI: 0.24-1.06, p = 0.072). On the other hand, the justified / relevant nature of the passage appears more frequent in patients who have symptoms progressing for less than 24 hours (OR = 1.85, 95% CI: 1.25-2.72, p = 0.002) and for those who have consulted the internet (OR = 2.11, 95% CI: 1.25-3.56, p = 0.005).

 

CONCLUSION:

Our study showed that certain criteria influence emergency room visits: age, level of study and date of onset of symptoms <5 days. It also highlighted more unjustified passages in patients visiting medical information sites or consulting the internet daily.

Camille AUROUX, Aurélien MULLIEZ, Thomas FLEUCHOT, Jean-Baptiste BOUILLON, Dorian TEISSANDIER, Mélissa FLEURY, Virginie GOULVIN, Sara SERRAR, Julien RACONNAT, Jeannot SCHMIDT, Farès MOUSTAFA (Clermont-Ferrand)
00:00 - 00:00 #22894 - Impact study of rapid diagnosis of influenza in an emergency department during the 2018 2019 epidemic season.
Impact study of rapid diagnosis of influenza in an emergency department during the 2018 2019 epidemic season.

Introduction : Influenza occurs seasonally and affects between 3 and 6 million people each year, resulting in a sharp increase in emergency consultations. With the arrival of the rapid point-of-care testing (POCT), the questions of the use of this technology arose. The main objective of this study was to show that the use of POCT in emergency department could reduce the length of stay of these patients.

Method : We conducted a prospective, monocentric, randomized and controlled study in a French Universitary hospital between january and march 2019. Patient presenting with a suspected flu were randomly assigned to the laboratory group (standard of care performed in the laboratory with Simplexa Flu A/B & RSV Direct Diasorin) or to the point-of-care testing (POCT with Xpert Flu/RSV Cepheid). The two devices have equivalent sensitivity and specificity (97,9%/99,4%). The primary outcome was the length of stay in the emergency department. This study received an ethical approval by the ethic committee of Sud-Ouest et Outre-Mer II.

Results : 203 patients were included with 111 (54.7%) in the POCT group and 92 (45.3%) in the laboratory group. An overall decrease in emergency department length of stay was highlighted by 1.7 hours (p=0.02, 95%CI: 1.13-2.42) and more specifically by 3.5 hours (p=0.02, 95%CI: 1.48-4.17) in the influenza patient subgroup. Without, however showing any evidence of significant increase in costs (p=0.17).

Conclusion: This study shows the value of using point-of-care testing by rapid influenza diagnostic test in emergency unit in the management of patients suspected of influenza during the epidemic periods. With sensitivity and specificity equivalent to the techniques used by the laboratory, its proper use allows a reduction in emergency time without significant increases in costs.

Alizée GAGNAIRE, Julien RACONNAT, Jeannot SCHMIDT, Cecile HENQUELL, Amélie BREBION, Virginie GOULVIN, Marie THOMAS, Mélissa FLEURY, Farès MOUSTAFA (Clermont-Ferrand)
00:00 - 00:00 #23063 - Improvement of an emergency referral system in a low resource context through the implementation of a new triage protocol: a quasi-experimental study.
Improvement of an emergency referral system in a low resource context through the implementation of a new triage protocol: a quasi-experimental study.

Background

To strengthen health services in the Beira district, Mozambique, after the Idai Cyclone, an ambulance emergency referral system was implemented by the Italian NGO CUAMM - Doctors with Africa. With an average of 800 patients transported each month from the peripheral primary care centers (CS) to Beira Central Hospital (HCB), the system worked at the full capacity. Initially, the selection of transported patients was based on the clinical experience. To improve the appropriateness of the referrals, CRIMEDIM - Research Center in Emergency and Disaster Medicine (Università del Piemonte Orientale, Novara, Italy) implemented the South African Triage Scale (SATS) in three of the 15 CS covered by this system. A two-days course focused on SATS was delivered to the local personnel and an operation manual was developed and made available.

 

This study aims to assess whether the implementation of SATS had a positive impact on the appropriate selection of critical patients who needed urgent transport and to assess the accuracy of the triage performed by the local personnel.



Methods

This quasi-experimental study is composed of two periods: a pre-implementation phase, from 08/10/2019 to 07/12/2019, where patients were assessed, selected, loaded in the ambulance and transferred without using the SATS; and a post-implementation phase, from 08/12/2019 to 08/02/2020, where patients were assessed, selected, loaded in the ambulance and transferred following principles and rules stated out in the SATS and in the referral protocol. The data of the transported patients was gathered from the referral charts. The measured outcomes were expected code (triage code retrospectively calculated by researchers using the information from the referral charts), triage accuracy (percentage of assigned codes matching with expected ones) and under and over-triage rates (assigned codes lower or higher than expected ones respectively). Pearson's Chi-square Test was used to investigate if distribution of color codes sent to hospitals and time in which they have been sent were independent. A hypothesis test was used to look at the proportions between the single categories, to analyze in which of them the null hypothesis could be rejected.



Results

A total of 979 referral charts were collected. 209 records were excluded and 770 records were analyzed, 552 from the pre-implementation phase and 218 from the post-implementation phase. The number of transported red codes increased (+10,54%)  and the number of green codes decreased (-12,71%), both with a statically significant difference. Accuracy was 30% for green codes, 29,3% for yellow, 20,2% for orange, 39,4% for red. The overall rate of accuracy, over and under-triage were 29,22%, 47,49% and 23,28% respectively.

Discussion & Conclusions

This study demonstrated that the introduction of SATS, in this low resource context, modified the pattern of transported patients. It showed an increase of red codes transported and a reduction of green codes. Although the accuracy of the triage performed by local professionals can be considered low, the implementation of this triage protocol significantly reduced the number of non-urgent transports. We recommend the inclusion of a triage protocol in the design of emergency referral systems for developing countries.

Andrea CONTI, Lorenzo LORA RONCO, Daniela SACCHETTO, Marta CAVIGLIA, Francesco BARONE-ADESI, Marcello MAZZOTTA, Helga LANGUANA, De Meneghi GIOVANNA, Emanuela DE VIVO, Giovanni PUTOTO, Filomena ATANASIO, Priscila FILIMONE, Cizalia FIGUEIRA, Fino MASSALAMBANE CHALIMBA, Francesco DELLA CORTE, Luca RAGAZZONI (Novara, Italy)
00:00 - 00:00 #23192 - Incidence of Delayed and Missed Diagnosis of Carbon Monoxide Poisoning in the Emergency Department: A Multicenter, Retrospective Analysis.
Incidence of Delayed and Missed Diagnosis of Carbon Monoxide Poisoning in the Emergency Department: A Multicenter, Retrospective Analysis.

Introduction: Carbon monoxide (CO) is increasingly recognized as a serious and relatively common cause of intoxication. It is also estimated to affect about 50,000 patients per year in the United States, with an annual mortality rate between 1000 and 2000. Its clinical manifestations can be subtle and non-specific, thus broadening the differential diagnosis. In current literature, only a few works examine the incidence of CO poisoning, and none addressed the incidence of problems in diagnosing this ominous intoxication in the emergency department (ED).

With this study we investigated the incidence of delayed and missed CO poisoning diagnosis in the ED, to evaluate the burden of such an event.

Methods: This retrospective study was carried out by reviewing carboxyhemoglobin values measured with point-of-care analyzers among the EDs of North-east Italy. The analysis included patients that accessed the EDs between June 2014 and July 2019 and had COHb values > 10%, without limitations of age or gender. Normally, non-smokers are diagnosed with CO intoxication if COHb values are above 4%, while smokers must have values above 10%. We chose the cutoff of 10% because smoking habits are usually not disclosed in ED charts, thus underestimating the phenomenon but increasing the specificity of our results. Patients' charts were consulted to quantify delayed and missed diagnoses. As the primary outcome, a diagnosis was defined as "missed" if no mention of CO intoxication was found in the chart or in the diagnosis of discharge or hospitalization. Lacking a benchmarking value, a diagnosis was defined as "delayed" if the blood analysis was performed after 30 minutes from the beginning of the medical examination (secondary outcome).

Results: Out of 126,000 analyses, 127 patients were included in the study (Male: 55.1%; age: median 47 years old, IQR = 32 – 55 years old). Median COHb value was of 14.3% (IQR = 10.9 – 20.3; min: 10.1%; max: 39.8%). Only 54 patients received a diagnosis of CO poisoning (42.5%) and only 52 were treated with oxygen. Of the 73 missed diagnoses, 42 were then discharged. Moreover, a diagnostic delay was found in 13 out of 127 patients (10.2%).

Discussion and Conclusions: There is a significant number of delayed CO poisoning diagnoses and an even higher number of missed diagnoses. This study did not investigate the clinical consequences of such mistakes. However, it is well known that a delayed or, even worse, a missed diagnosis of CO intoxication can have serious impacts on the outcome of patients, in terms of possible end-organ damage such as delayed neurologic sequelae. More worrying, discharging a patient back to an unnoticed, contaminated environment could have fatal consequences. This study depicts an unprecedentedly reported problem that should prompt quality improvement processes to increase the awareness about this ominous intoxication and the level of care delivered by emergency medicine physicians and healthcare systems. In the future, a wider study including other EDs will clarify if this phenomenon is diffused or restricted to only a cluster of EDs.

Matteo PAGANINI (Padova, Italy), Lucia CONFENTE, Francesco BARONE-ADESI, Mara ROSADA, Claudio RAMPONI, Gerardo BOSCO
00:00 - 00:00 #22443 - Incidence, mortality and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.
Incidence, mortality and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

Background: Primary postpartum haemorrhage remains the primary cause of maternal mortality in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited. This study was designed determine the incidence mortality, and factors associated with primary postpartum haemorrhage following in-hospital births.

Methods: This was a cross-sectional study design, an audit of 1060 maternity care logbooks of discharged women at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted December to May 2018/2019 using systematic random sampling. Exclusion criteria were logbooks of women aged less than 18 years old or women with maternity care logbooks which had been transferred to another department. The tool used was the Facility Based Maternal Death Abstraction Form. The diagnosis of the woman’s primary postpartum haemorrhage was informed by one of two methods. The first was by the estimated blood loss recorded by the staff. The second was the medical staff diagnosis and recording of the woman as having primary postpartum haemorrhage. Data were entered, cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance.

Results: The incidence of primary postpartum haemorrhage was nearly 9.0%. Of these, there was 7% maternal mortality. Predominant to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by final year medical students (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p<0.05).

Discussion & Conclusions: This study found that the reported incidence of primary postpartum haemorrhage was relatively low, however, the associated deaths of women found was comparatively high. Most factors contributing to incidence of primary postpartum haemorrhage were similar to those found in previous studies. However, three factors prevail for women in Ethiopia, women discharged 6 hours post-partum, transfers from primary health centres, birth attendance by final year medical students.

Funding: This study was unfunded

Ethical approval and informed consent: Prior to commencing data collection ethics approval was sought and approved by Human Research Ethics Committee, Monash University (Project ID: 14113) on 24/08/2018 and Institutional Review Board for Human Research of the University of Gondar on December 20/2018. As the women were already discharged, and not all contactable in rural areas, they could not consent to this research retrospectively providing permission to the reviewing of their maternity care logbooks. The ethics committees granted a waiver of consent.

Bewket Tadesse TIRUNEH (FRANKSTON, Australia), Gayle Mclelland MCLELLAND, Virginia PLUMMER
00:00 - 00:00 #23561 - Increased S-100 B levels are associated with fractures and soft tissue injury in multiple trauma patient.
Increased S-100 B levels are associated with fractures and soft tissue injury in multiple trauma patient.

Background: S-100 B protein was identified a biomarker for traumatic brain injury, but studies suggest that extracranial injuries may also lead to increased S-100 B serum levels. In this study, we aim to quantify the impact of injury patterns on S-100 B levels in patients with suspected multiple trauma.

Methods: Patients with suspected multiple trauma treated at a Level 1 Trauma centre in Switzerland were included in this retrospective patient chart review. Extent of injuries and severity was assessed and S-100 B levels on admission measured. Potential predictors of increased S-100 B levels (>0.2 µg/L) were identified through uni- and multivariable analyses.

Results: 1,338 patients with suspected multiple trauma were included. Multivariable logistic regression showed a significant association with increased S-100 B levels in long bone fracture (OR 2.3, 95% CI: 1.3-4.1, p=0.004), non-long bone fracture (OR 3.0, 95% CI: 2.2-4.3, p<0.001), thoracic injury (OR 2.6, 95% CI: 1.6-4.2, p<0.001), and deep tissue injury/wounds (OR 1.9, 95% CI: 1.4-2.6, p<0.001). Head trauma with intracerebral bleeding was only weakly associated (OR 2.0, 95% CI 1.2 - 3.5, p=0.01) and head trauma without intracranial bleeding was not associated with an increased S-100 B protein level (p=0.71). Trauma severity was also related to increased S-100 B levels (OR per ISS: 1.1, 95% CI 1.0-1.1, p<0.001). S-100 B levels <0.57 µg/L had a high diagnostic value to rule out in-hospital mortality (negative predictive value: 1.0, 95% CI: 0.98-1.00).

Conclusion: Fractures and thoracic injuries appeared as main factors associated with increased S-100 B levels. Head injury may only play a minor role in S-100 B protein elevation in multiple trauma patients. A normal S-100 B has a good negative predictive value for in-hospital mortality. S100-B levels were associated with trauma severity and might thus be of use as a prognostic marker in trauma patients.

Martin MÜLLER, Wolf HAUTZ, Joel GERBER, Joerg SCHEFOLD, Aristomenis EXADAKTYLOS, Carmen PFORTMUELLER (Bern, Switzerland)
00:00 - 00:00 #22943 - Independent determinants of emergency department length of stay in different triage categories: an observational study using the Netherlands Emergency department Evaluation Database (NEED) for benchmarking.
Independent determinants of emergency department length of stay in different triage categories: an observational study using the Netherlands Emergency department Evaluation Database (NEED) for benchmarking.

Background

Benchmarking is an important tool in quality improvement, but is hardly done in Dutch emergency departments (EDs). As “proof of principle” study, we assessed independent determinants, including ED location, of ED length of stay (LOS)>4 hours as one important aspect of quality of care. This was done per triage category because we assumed that benchmarking of EDs should be done per disease severity category. 

Methods

An observational multi-centre study including all visits of three EDs in the Netherlands Emergency department Evaluation Database (NEED), the Dutch Quality registration for EDs. Patients were stratified by triage category; ‘non-urgent’ (blue&green), ‘urgent’ (yellow), ‘very urgent’ (orange) and ‘immediate’ (red). In every triage category, independent determinants (including ED location A, B, or C as potential determinant, with A being the reference) of ED-LOS>4hrs (primary outcome) were assessed using multi-variable logistic regression analysis.

Results

We included 172.104 ED visits. Independent determinants of ED-LOS>4hrs differed per triage category, with ED location being an independent determinant in all triage categories except ‘red’. The three most important independent determinants of ED-LOS >4hrs in triage category ‘blue&green’ were >2 consultations in the ED (Adjusted Odds Ratio (AOR(95%-CI)) 3.92(3.39-4.54), the presenting complaint ‘intoxicated’ (3,63(2.39-5.54) and  blood sampling 3.56(3.23-3.93). For ‘yellow’ these were >2 consultations (4.61(4.25-5.01), ‘intoxicated’ 3.50(2.88-4.24), and visiting hours 0-6PM (2.97(2.79-3.28, reference was 0-6AM). In ‘orange’ these were ‘intoxicated’ 3.46(2.79-4.30), >2 consultations 3.45(3.16-3.75), and ‘ED location B’ (2.21(1.99-2.46). In ‘red’ these were >2 consultations 2.62(2.10-3.27), headache 2.91(1.37-6.17) and fluid administration >500ml in the ED (1.75(1.34-2.29). 

Discussion

Our “proof of principle” study suggests that benchmarking of EDs with respect to ED-LOS should be done per disease severity category given the different independent determinants  found in triage categories and the different impact of ED location per triage category. Our study shows in which way the NEED can be used for benchmarking EDs with respect to ED-LOS. 

Wouter RAVEN (Leiden, The Netherlands), Christine ROELOFSEN, Menno GAAKEER, Ter Avest EWOUD, Ozcan SIR, Heleen LAMEIJER, Roger HESSELS, Resi REIJNEN, Erik VAN ZWET, Evert DE JONGE, Bas DE GROOT
00:00 - 00:00 #23256 - Instructional Programs Influencing the Enhancement of the Awareness and Knowledge Required by Volunteers in Disasters: A Systematic Review.
Instructional Programs Influencing the Enhancement of the Awareness and Knowledge Required by Volunteers in Disasters: A Systematic Review.

Background and Objectives: The majority of countries around the globe are disaster-prone and volunteers have proved a pervasive and comprehensive presence in various disasters. Nonetheless, a shortage of knowledge and awareness has always been detected among volunteers. The present study aimed at determining the instructional programs required by volunteers based on the studies carried out worldwide.

Methods: A systematic search was carried out in PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science, and ProQuest databases between January 1970 and end of June 2019. The articles were selected based on the keywords chosen by the author. In the end, the instructional titles required for volunteers in disasters were extracted from the articles.

Results: After studying the titles, abstracts, and complete texts of the articles, eleven articles were chosen for final analysis following which 45 instructional titles were extracted. The most frequent scales in terms of repetition were ethics, kinds of exercises, personal protection instruments, general hygiene, awareness of certain disasters, accident command system, disaster triage, and emergency planning.

Conclusion: Considering the daily increasing growth in the number of volunteers in natural and manmade disasters, governments should offer programs that can best serve the improvement of their performance. Universities and schools play determinant roles in this regard. It is hoped that the present study findings can be effective in codifying an efficient instructional program for elevating the performance of the volunteers taking part in response to disasters.

Peyravi MAHMOUDREZA, Rezaee RITA, Ahmadi Marzaleh MILAD (Shiraz, Islamic Republic of Iran)
00:00 - 00:00 #23118 - Intracranial hemorrhage in an infant due to severe factor V deficiency.
Intracranial hemorrhage in an infant due to severe factor V deficiency.

Background and Objectives: Coagulation factor V (FV), that has both procoagulant and anticoagulant functions, plays a role in the blood coagulation cascade. FV deficiency is a rare coagulation disorder with an estimated incidence of 1 in 1,000,000. Affected patients become symptomatic in early childhood with spontaneous or post-traumatic bleeding complications. In these patients, it can be observed variable spectrum of bleeding manifestations ranging from mucosa and soft tissue bleeding (such as epistaxis and hemarthroses) to life-threatening hemorrhages. In this report, it was presented an infant with intracranial hemorrhage due to severe factor V deficiency.

Case report: A 8-month-old male admitted to the emergency department (ED) with pallor, fever, decreased feeding and lethargy for 2 days. He had also a seizure that lasted about within 5 minutes, 6 hours before the presentation. There was no history of previous illness or head trauma. There was no family history of bleeding diathesis. The mother had a normal pregnancy with full antenatal care. 1 mg of Vitamin K was given intramuscularly after the delivery. Upon arrival to the ED, he was irritable and had severe pallor. His body temperature, pulse, blood pressure and oxygen saturation were 38.2 oC, 170/min, 86/48 mm Hg and 99%, respectively. His pupils reacted normally to light and ocular movements were normal. No evidence of raised intracranial tension such as hypertension, bradycardia, hypoventilation or a full fontanelle. Laboratory assessment revealed the hemoglobin of 6.4 mg/dL, platelet count of 357000/mm3,  international normalized ratio (INR) 4.2, Prothrombin time (PT) 42, activated partial thromboplastin time (APTT) 98. Brain CT showed 5.5 x6 centimeter intracranial hemorrhage in left frontal area with right shift. While all the other factor levels were in the normal range, his Factor V levels were less than 1%confirming a diagnosis of severe FV deficiency. After rapid fresh frozen plasma and erythrocyte suspension were given, the patient was operated. After intensive care follow-up, he completely recovered.

Conclusion: Although FV deficiency is rare in childhood, that should be kept in mind in patients with unexplained bleeding and be treated quickly.

Aslı GÜZEL, Dr Ali YURTSEVEN (İzmir, Turkey), Pınar YAZICI, Halit IŞIK, Bulent KARAPINAR, Eylem Ulas SAZ
00:00 - 00:00 #22257 - INVISIBILY CLOAK: RECOGNITION DELAY OF ATYPICAL STROKE SYMPTOMS IN PATIENTS WITH MORE THAN 75 YEARS.
INVISIBILY CLOAK: RECOGNITION DELAY OF ATYPICAL STROKE SYMPTOMS IN PATIENTS WITH MORE THAN 75 YEARS.

FOREWORD: Stroke is one of the main causes worldwide of mortality and residual disability (about 35% of stroke patients remain with severe impairment), representing the leading cause of disability in elderly people. Over the past 25 years, since 1990 to 2010, prevalence of stroke has gradually raised in a directly proportional way to increasing age. Although it is a time-dependent disease, its early detection can sometimes be insidious, leading to delays in assistance and therapy.

 

PURPOSE: According to different symptomatological spectrum at presentation, the purpose of this study is to analyze times needed for recognition (in terms of attribution of priority codes to medical examination and waiting time) and management of patients over 75 years affected by stroke evaluated in our Emergency Department. Methods: We conducted a prospective and monocentric observational study of all patients with acute stroke referred to the Department of Emergency and Acceptance of the IRCCS Polyclinic Foundation S. Matteo in Pavia  from May 1, 2017 to May 1, 2018.

 

RESULTS: We enrolled a total of 430 patients with more than 75 years who received diagnosis of stroke at our Emergency Department from May 1st 2017 to May 1st 2018. The average age was 83.8y and women were in slight majority (female 60%). At presentation, symptomatological spectrum was so divided: 56.7% (242 patients, pt) motor symptoms, 15.7% (67 pt) sensory symptoms, 46.8% (200 pt) speech disorder and 36.5% (156 pt) atypical symptoms (including dizziness, confusion and syncope). The four groups appeared to be superimposable by age, gender distribution, number of risk factors and hospitalization outcome. While the first three groups with typical symptoms accurately presented an high priority code for medical examination (about 90% had yellow code or higher), only 74% of patients belonging to the forth group (atypical symptoms) had a high priority code for medical examination. This resulted in different waiting times: average of 38 minutes (min) and median of 20 min for the first three categories, average of 55 min and median of 27 min for patients with atypical symptoms. This time delay in the fourth group was primarily dependent on recognition at door, while subsequent times (request for imaging, neurological consultation and process time) were normalized with respect to other three symptomatological categories after the medical examination. CONCLUSIONS: As our results demonstrated, patients presenting atypical symptoms of stroke were more difficult to recognize at door as neurological acuities, leading to increased waiting times. However, at medical examination these patients were rapidly recognized, thanks to multidisciplinary collaboration between Emergency Doctors, Neurologists and Interventional Radiologists, and there was no further delay in management and treatment times. Therefore, it’s important to pay attention in order to identify risk factors that could allow earlier recognition at triage especially in patients presenting atypical symptoms.

Dr Gabriele SAVIOLI (PAVIA, Italy), Iride Francesca CERESA, Mirko BELLIATO, Anna CAVALLIN, Alessandra PERSICO, Giovanni RICEVUTI, Chiara GAGLIARDONE, Andrew WIMER, Francesco GERACI, Maria Antonietta BRESSAN
00:00 - 00:00 #23035 - Is a whole-blood protocol a viable alternative to component therapy in haemorrhaging major trauma patients: a systematic review.
Is a whole-blood protocol a viable alternative to component therapy in haemorrhaging major trauma patients: a systematic review.

Background

At present, blood component therapy is considered the gold-standard treatment for haemorrhaging major trauma patients. In the military setting, soldiers are commonly transfused with whole-blood and studies involving this patient group have demonstrated the benefits of this method. Military procedures are often found to be effective within civilian major trauma patients and then implemented accordingly as shown recently with the CRASH-2 study.

 

Methods

Our study is a systematic review aimed to identify if the use of whole-blood should replace component therapy as common civilian major haemorrhage protocol.

A review of published literature was performed to identify studies or control trials which explored the use of whole-blood in military or civilian major trauma patients. Articles from the past 10 years (2010-2020), involving humans in the English Language were searched within PubMed and MEDLINE. Excluded were paediatric patients and singular case studies.

 

Results

306 articles were identified with 16 papers included for analysis. The papers were then placed into 4 different topic groups based on their focus: clinical outcomes and transfusion volumes (n=6): safety, feasibility and implementation (n=4); effects on coagulation (n=2); storage and processing (n=4).

11 papers produced results in favour of whole-blood use amongst trauma patients; improved survival (n=2; CI=0.02-0.53; 1.314-7.618), decreased transfusion volume after sensitivity analysis (n=1; p=0.02), shortened time to normalised lactate (n=1; p=0.05), reduced traumatic coagulopathy (n=1; CI=0.00-0.18), delayed benefit of whole blood use on coagulation (n=1), successful implementation of protocols (n=2), whole blood use is both feasible and safe (n=2), refrigeration of whole-blood attenuated decrease in aggregation and increase in prothrombin time (n=1; p ≤ 0.001).

5 papers produced results which opposed the use of whole-blood amongst trauma patients; no significant difference in clinical outcomes or transfusion volumes (n=2; p=0.24, p=0.33; p=0.52, p=0.72), minimal difference in coagulation effects between whole-blood and component therapy (n=1), filtration has a negative impact upon platelet aggregation (n=2), leukoreduction has a negative impact upon platelet aggregation (n=1).

Overall, the majority of papers showed potential benefits to the use of whole-blood in haemorrhaging major trauma patients.

 

Conclusions

There are potential benefits to implement a whole-blood centred protocol. However, further discussion must take place within the medical profession. This should include larger scale randomised control trials exploring the direct impact of lactate clearance in major trauma patients upon clinical outcomes and a cost comparison to ascertain the most economically viable protocol.

Abigail CLYNCH, Jayden GITTENS, Abdo SATTOUT (Liverpool, )
00:00 - 00:00 #23176 - Is there a role for abdominal plain films in patients suspected of having renal colic?
Is there a role for abdominal plain films in patients suspected of having renal colic?

Background:   Renal colic is often very painful, but rarely dangerous.  For most patients, making the diagnosis of renal colic “rules out” other potentially dangerous diseases such as aortic aneurysm and appendicitis.  Non-contrast computed tomography (NCCT) has been touted as the best radiology test for renal colic, but has high cost and radiation exposure.  The abdominal x-ray (KUB) together with renal ultrasound have been proposed as an alternative to NCCT.  We sought to determine whether the KUB alone could reduce NCCT testing.

Methods: Study Design: Retrospective cohort.   Population: 1000 consecutive patients from 7-1-17 to 12-31-17 who received a NCCT at a suburban community teaching hospital with annual ED visits of 90,000.  Here, when a NCCT is ordered for suspected renal colic, a KUB is obtained automatically as per the hospital radiology “renal stone protocol.”  (NCCTs may also be done for other reasons.)  We randomly sorted 1000 records of NCCTs and arbitrarily chose the first 188; 74 had no KUB, leaving 114 for further analysis.  The KUBs and NCCTs were initially interpreted together by attending radiologists. One of the radiologists re-read the 114 KUBs without knowledge of the NCCT results and reported each KUB as being positive, negative or indeterminate for ureteral stones found on NCCT (the latter usually because of problems distinguishing stones from phleboliths).  We calculated sensitivities, specificities and likelihood ratios (LRs) and their 95% confidence intervals (CIs) for the diagnosis of urolithiasis for the KUB, using the NCCT as the criterion standard.

Results:  The median age was 52 years (interquartile range: 41, 61); 54% were female.  Fifty-one (45%) had a positive NCCT and 34 (30%) had a positive KUB.  Using the NCCT as the criterion standard, the number of true positives, true negatives, false negatives and false positives for the KUB were 34, 63, 17 and 0, respectively. The sensitivity and specificity of the KUB for urolithiasis were 67% (95% CI 52, 79%) and 100% (95% CI 93, 100%), respectively. The LRs associated with a negative and positive KUB were 0.33 (95% CI:  0.23, 0.49) and infinity (95% CI: 14, infinity), respectively.

Conclusion: The specificity and the positive LR for the KUB are high, so when the KUB is “positive” the diagnosis is almost certainly renal colic.  Since 30% of the patients had a positive KUB, using the KUB as the initial test could reduce NCCTs by 30%.

 

Daniel JOHNSON (Morristown, USA), Barnet ESKIN, John ALLEGRA, Sean CALHOUN
00:00 - 00:00 #23529 - Lack of association between four biomarkers and the presence of persistent post-concussion symptoms after a mild traumatic brain injury.
Lack of association between four biomarkers and the presence of persistent post-concussion symptoms after a mild traumatic brain injury.

Background: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI.

 

Methods: Study design and setting: This multicentre prospective cohort study took place in seven large Canadian Emergency Departments (ED) (five level I trauma centres, one level II trauma center and one academic non-trauma centre) between 30/04/2014 and 30/09/2018. Inclusion criteria: patients aged ≥14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Exclusion criteria: Patients who were admitted following their ED visit or unable to consent. Procedures: Consecutive potential participants were identified by the treating emergency physicians. Informed consent was obtained, sociodemographic and clinical data as well as blood samples were collected in the ED. A research assistant then conducted phone follow-ups at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). Primary outcome: The presence of persistent symptoms at 90 days after mTBI, as assessed using the RPQ. Statistical methodsA ROC curve was constructed for each biomarker.

 

Results1276 patients were included in the study. The median age for this cohort was 39 (Q1-Q3: 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively.

 

ConclusionAmong mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.

Natalie LE SAGE (Québec, Canada), Jérôme FRENETTE, Jean-Marc CHAUNY, Simon BERTHELOT, Patrick ARCHAMBAULT, Jeffrey PERRY, Jacques LEE, Eddy LANG, Andrew MCRAE, Xavier NEVEU, Pier-Alexandre TARDIF, Valérie BOUCHER, Éric MERCIER, Marcel ÉMOND
00:00 - 00:00 #22511 - Lactate and glucose levels at ambulance like predictors of in-hospital early mortality in acute cardiovascular disease: a prospective, multicenter study.
Lactate and glucose levels at ambulance like predictors of in-hospital early mortality in acute cardiovascular disease: a prospective, multicenter study.

Background: Acute cardiovascular disease (ACVD) represents the leading cause of mortality in our environment, and especially coronary heart disease. For every 30 minutes of delay in the management of acute myocardial infarction, the one-year mortality rate increases by 7.5%, so time is a determining factor to minimize morbidity and mortality.

The objective of this study is to compare the diagnostic accuracy of two prehospital biomarkers: lactate (pLA) and glucose (pGL) to predict early mortality (less than two-days) in patients with AVCD treated by emergency medical services.

Methods: Multicentric prospective observational longitudinal study, between June 22, 2018 and October 30, 2019. The study was developed on Castilla y León region (Spain). All adult patients with ACVD treated consecutively by the emergency medical services and transferred to the emergency department of their referral hospital were included in the study. Patients who did not require evacuation or discharged in situ, cases with terminal pathologies, pregnant women and cardiorespiratory arrest were excluded.

Demographic data (age and gender) and analytical determinations were obtained by the emergency registered nurse during the first emergency medical services contact with the patient. The FreeStyle Optium Neo device (Abbott Laboratories, Illinois, USA) was used to determine blood glucose values, with a measuring range of 20-500 mgr / dl. The Accutrend Plus device (Roche Diagnostics, Mannheim, Germany), with a measurement range of 0.8-21.7 mmol/L, was used to obtain the lactic acid values. All measuring devices were calibrated every 50 determinations, always by the same researcher, using the Accutrend® BM-Control-Lactate control solution (Roche Diagnostics, Mannheim, Germany).

At 2-days of the index event, by reviewing the patient's electronic history, hospital admission and 2-day mortality data were obtained. The main outcome variable was early hospital mortality (within the first 48 hours) from any cause.

The area under the curve (AUC) of the receiver operating characteristic (ROC) of the pLA and pGL was calculated in terms of 2-day mortality. Youden's test  was calculated for the cut-off point with better sensitivity and specificity combined for each biomarker.

Results: a total of 1296 patients with ACVD were included in our study. The median age was 67 years (IQR: 51-81 years), with 504 females (38.8%). The 2-day mortality was 3.85% (50 cases).

The AUROC of pLA was 0.934 (95% CI: 0.88-0.98; p> 0.001) and for pGL was 0.636 (95% CI: 0.55-0.72; p = 0.002). The cut-off point for the pLA was 4.1 mmol / L with a sensitivity of 0.96 (95% CI: 0.90-1) and a specificity of 0.83 (95% CI: 0.81-0.85)

and for the pGL of 171 mg / dl with a sensitivity of 0.46 (95% CI: 0.32-0.59) and a specificity of 0.79 (95% CI: 0.77-0.82).

Conclusions: Routine use of biomarkers can help stratify the risk of deterioration in patients with ACVD early. The performance of the pLA is excellent, far superior to that offered by the pGL. In view of the data, the determination of the pLA should be a routine procedure in all advanced life support units, providing very useful information about your close prognosis.

Francisco MARTÍN-RODRÍGUEZ, Carlos DEL POZO VEGAS (Valladolid, Spain), Raúl LÓPEZ-IZQUIERDO, Juan Francisco DELGADO BENITO, Ana GIL CONTRERAS, Elena MEDINA LOZANO, Irene SÁNCHEZ SOBERÓN, Ancor SANZ GARCÍA, Ana Belén LÓPEZ TARAZAGA, Germán FERNÁNDEZ BAYÓN, Laura Natividad FADRIQUE MILLÁN, Miguel Ángel CASTRO VILLAMOR, Leonardo RODRIGUES, Virginia CARBAJOSA RODRÍGUEZ, Tony Giancarlo VÁSQUEZ DEL ÁGUILA, Iratxe MORO MANGAS
00:00 - 00:00 #22650 - Left without being seen: a quality indicator in the emergency department.
Left without being seen: a quality indicator in the emergency department.

Left without being seen: a quality indicator in the emergency department

Rafael Kneuts, Inge Roggen, Ives Hubloue

 

Abstract

Background: Patients leaving the emergency department (ED) without being seen (LWBS) by a physician are a worldwide known phenomenon. These patients represent 0.36 to 15% of the total number of patients visiting the ED, depending on the region and the settings of the ED. We wanted to identify the prevalence and possible causes of this phenomenon in a large tertiary ED, with 75000 yearly visits.

 

Methods: A prospective study was conducted with patients of one large tertiary ED. Between 01/06/2018 and 30/11/2018, patients who had left the ED prematurely were contacted by phone, one week after their ED visit. A standardised questionnaire was used to conduct a phone survey. Additional information was acquired from the patient’s medical record. Statistical analysis was performed using MedCalc® version 18.11.3 (MedCalc Software bvba, Mariakerke, Belgium). All data are presented as mean ± standard deviation (SD) or as median (range), when not normally distributed. D'Agostino-Pearson K-squared test was used for assessing normality of data. Spearman’s rho test was used to calculate rank correlation coefficients.

 

Results: 598 out of 30127 patients (1.98%) left the ED prematurely, of which 509 (85.1%) were contacted by phone and 259 (43.4%) agreed to participate. LWBS patients were significantly younger, and the degree of emergency was significantly lower compared to the general population.

The top 3 of the main reasons why people left the ED prematurely were the waiting time (74.9%), 13.1% suddenly felt better and 13.1% needed to be elsewhere. Of the LWBS patients, 40.1% are admitted between 6 pm and midnight, while only 31.7% of total ED visits take place in that timeframe.

 

Conclusion: In our ED, patients who LWBS are young adults with less severe diseases as reported in literature. The waiting times are the main reason why patients leave the ED prematurely. Strategies to reduce waiting times or to inform these patients about waiting times could be implemented to reduce LWBS.

Rafael KNEUTS (Brussel, Belgium)
00:00 - 00:00 #23126 - Low Doses of Ketamine infusion in the treatment of moderate to severe acute pain in the Emergency Department: Randomised controlled interventional trial.
Low Doses of Ketamine infusion in the treatment of moderate to severe acute pain in the Emergency Department: Randomised controlled interventional trial.

Opioid analgesics have been the analgesics of choice for the last decades in most emergency conditions, but these potent analgesics are not without negative side effects, particularly in uncontrolled scenarios, such as hypotension and hypoventilation. Currently approved as anesthetic agent, ketamine is finding new use as an off-label analgesic showing promise for severe pain control in the ED. Many studies of subanesthetic administration termed as low-dose ketamine (LDK) suggest that it provides analgesia with eventually minor adverse effects when administered in single bolus or as an adjunct to opioids. We suppose that Ketamine infusion is an alternative option which can provide the same analgesic efficacy with less adverse effects.

The aim of the trial study is to study the analgesic efficacy and side effects of intravenous infusion of two doses of ketamine versus IV bolus in the emergency settings. We performed randomized, prospective, double-blinded trial at the emergency department of Farhat Hached university Hospital in Sousse, Tunisia. A sample of patients aged 18 to 65 years with moderate to severe acute pain, were enrolled. Subjects were consented and randomized to three groups; 0.3mg/kg of ketamine through an IV push; 0.3mg/kg of ketamine over 5 minutes and 0.6mg/kg over 10 minutes. Our primary outcome was the maximum change in Numeric Rating Scale (NRS) scores and secondary outcomes were patients’ satisfaction, the use of rescue analgesia (morphine) and the side effects of LDK.

59 patients were enrolled with similar demographic characteristics. The group receiving 0.3mg/kg of ketamine through an IV push appeared significantly more efficient from T45 until the end of the study. The 0.3mg/kg IV push Group patients showed a higher PRS than the other groups from 30 minutes after the beginning of the protocol until the end of the study. The use of rescue analgesia was significantly lower in the group receiving 0.3mg/kg of ketamine through an IV push compared with the other two groups. No major side effects were observed during the study. Psychomimetic events were more frequently observed in the group receiving 0.6mg/kg of ketamine over 10 minutes.

Ketamine has been effective in the management of moderate to severe acute pain, but the 0.3mg/kg IV push group has been associated with a larger decrease in NRS, a longer maintenance of analgesic effect and a less common reliance on rescue analgesia. We recommend to conduct further studies with larger samples to evaluate the efficacy and safety of the use of 0.3mg/kg of ketamine through an IV push associated or not with the same drug infusion in order to deal with moderate to severe acute pain.

Dr Ahmed MAHMOUDI (Sousse, Tunisia), Hajer KRAIEM, Mohamed BEN REJEB, Mariem KHALDI, Hajer SANDID, Zied MEZGAR, Mehdi METHAMEM
00:00 - 00:00 #23458 - Lung ultrasonography features and risk stratification in COVID-19 patients: a prospective observational cohort study.
Lung ultrasonography features and risk stratification in COVID-19 patients: a prospective observational cohort study.

Background: Chest imaging is a key tool for the management of COVID-19 patients in the emergency department (ED). A correlation between chest CT features and COVID-19 severity has been demonstrated, suggesting a potential use as a triage tool. However, systematic chest CT in COVID-19 patients may overwhelm available resources during an outbreak, and is costly and associated with a high risk of nosocomial infections. Point-of-care lung ultrasound (LUS), already widely used in EDs, can be performed at the bedside of patients requiring protective isolation. However, data on its use for early risk stratification of COVID-19 ED patients is lacking. This study describes and compares early LUS characteristics across of range of clinical outcomes.

Methods: Prospective observational study of consecutive PCR-confirmed COVID-19 patients in the ED of Lausanne University Hospital. LUS images were recorded within 24hours of ED presentation using a standardized protocol, according to the “10-zone method”, with five zones per hemithorax (anterior-superior, anterior-inferior, lateral, posterior-superior, posterior-inferior). For every zone, the following patterns were reported and graded with a 0 to 3 points score: (1) normal appearance (A lines, < 3 B lines) = 0 points, (2) pathological B lines (≥3 B lines) = 1 point, (3) confluent B lines = 2 points, (4) thickening of the pleura with pleural line irregularities (subpleural consolidation < 1 cm) or (5) consolidation (≥ 1 cm) = 3 points. Each patient’s normalised score (nLUS score) was the sum of the graded points at every zone (possible range from 0 to 30 points) divided by the number of examined zones. Two experts, blinded to patients' outcome, retrospectively reviewed all images. LUS images were described and compared between patient groups based on their outcome on day 7 after inclusion, defined as: 1) self-resolving outpatients, 2) hospitalised, and 3) intubated/death. nLUS score was used to discriminate between groups.

Results: Between March 6 and April 3 2020, 80 patients were included (18 outpatients, 41 hospitalized and 21 intubated/dead); 73 patients (91%) had abnormal LUS (72% outpatients, 95% hospitalised and 100% intubated/death; p=0.004). The proportion of involved zones was lower in outpatients compared with other groups (median 30% [IQR 0-40%], 44% [33-70%] and 70% [50-88%], p<0.001). Predominant abnormal patterns were bilateral and multifocal thickening of the pleura with pleural line irregularities (70%), confluent B lines (60%), and pathological B lines (50%), affecting more often the posteroinferior zones. Median nLUS score was 0.45 (IQR 0.2, 0.8), 1.1 (IQR 0.62, 1.7) and 1.5 (IQR 1, 2) (P<0.001), with an area under the ROC curve of 0.81 (95% CI 0.70-0.92) between outpatients and the two others categories.

Conclusion: Our study shows that, in COVID-19 patients presenting at EDs, LUS using standardized procedures for acquisition and reporting, correlated to disease severity. A simple ordinal scoring system has the potential to discriminate patients requiring hospitalisation and thus better allocate scarce resources. LUS is a reliable, cheap and easy-to-use triage tool to decide on hospital admission. Although promising, the use of LUS for early risk stratification requires further studies with a larger sample size

Olivier HUGLI (Lausanne, Switzerland), Thomas BRAHIER, Jean-Yves MEUWLY, Olivier PANTET, Mary-Anne HARTLEY, Noémie BOILLAT-BLANCO
00:00 - 00:00 #23735 - Lung ultrasound and Coronavirus Disease-19 in the Emergency Department.
Lung ultrasound and Coronavirus Disease-19 in the Emergency Department.

Background: On January 30, 2020, the World Health Organization designated an outbreak of a Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). In most symptomatic patients, Coronavirus Disease 2019 (COVID-19) comprehend interstitial pneumonia that can be rapidly and early detected by bedside point-of-care ultrasound (POCUS).

Objective: Aim of the study was to check the performance of bedside lung ultrasound in the ED diagnosis of COVID-19 during the SARS-CoV-2 outbreak period.

Methods: We enrolled consecutive patients with ILI admitted to the Santa Maria Nuova ED in Florence from march 12th to April 12th 2020. ILI was defined as the presence of at least one symptom among fever, cough or dyspnea.  These patients were identified at a pre-triage area outside the hospital and managed separately from other patients according to infection control local protocols. All patients were tested for SARS-CoV-2 with nasal-pharyngeal swabs. According to the WHO guidance, COVID-19 diagnosis was defined as a positive result of real-time reverse transcriptase–polymerase chain reaction assay for SARS-Cov-2.For each patient we collected physical end anamnestic features, laboratory and diagnostic test results and outcome. For each patient we performed a point-of-care (POCUS) lung ultrasound. Based on the lung POCUS findings, we identified 5 ecographic patterns: A pattern (A-lines prevalence, normal B lines), cardiogenic B pattern (uniform, cranio-caudal progressing B pattern, possibly with pleural effusion), typical flogistic B or C pattern (single basal consolidation or focal B pattern), atypical flogistic pattern (apical or bilateral single consolidation and/or less than 3 focal B lines), C pattern (multiple consolidations), ARDS pattern (multifocal B pattern and multiple consolidations). C and ARDS pattern and according to sonographer opinion some atypical flogistic pattern (integrated point-of-care cardiac and inferior vena cava evaluation) were considered as possible COVID-19. We recorded the final diagnosis according to SARS-CoV-2 infection at hospital dismission or at 14-days follow-up.

Results: We enrolled 269 patients with COVID-like symptomps, mean age 66±20 years, 50,6% male gender. SARS-CoV-2 was found in 136 (50,6%) patients. Fifty (18,6%) more patients that never showed positive to naso-pharingeal swab are still under investigation. COVID-19 patients were male in 53,3%, mean age was 70±16 years. Among COVID-19 patients 67 (31,6%) needed oxygen supply, 24 (11,3%) required non-invasive ventilation and 12 (5,9%) needed Intensive Care Unit (ICU) admission. In-hospital mortality was 7,4% in COVID patients vs 4,7% in NO-COVID. Seven (3,4%) patients died at 14-days follow-up after hospital dismission. Most COVID-19 patients (63%, n=78) showed a C or ARDS pattern and 21 (10.3%) atypical flogistic pattern, while 14 (6,9%) showed a normal A pattern. POCUS showed 87% sensibility and 80% positive predictive value. Among 7 COVID-19 patients with negative nasal-pharingeal swab in ED, POCUS showed a COVID-suggestive pattern in 6 (86%).

Conclusions: In our experience POCUS is an useful tool for early COVID-19 diagnosis in ED. Lung ultrasound can help identifying potential false-negative SARS-CoV-2 testing and avoiding inappropriate patients managing, especially to prevent in-hospital infection spread

Lorenzo PELAGATTI, Elisa PAOLUCCI (Firenze, Italy), Simone BIANCHI, Caterina SAVINELLI, Erica SIBONA, Natalia FERSINI, Michele BUGGEA, Michele LANIGRA
00:00 - 00:00 #23250 - Machine learning for developing a prediction model of hospital admission of ED patients: hype or hope?
Machine learning for developing a prediction model of hospital admission of ED patients: hype or hope?

Background

Early insight in which emergency department (ED) patients need hospitalization could contribute to reduction of ED lengths of stay and thereby ED overcrowding with all its negative consequences. 

Aim

We aimed to develop prognostic models for prediction of hospitalization of ED patients with machine learning and conventional regression techniques.

Methods

Observational multi-centre cohort study using the Netherlands Emergency department Evaluation Database (NEED) in which all consecutive ED-patients of three hospitals were included. We assessed whether machine learning techniques were better than conventional multivariable logistic regression analysis by comparison of the discriminative performance (Area Under the Curve (AUC)) of the prediction models. Three machine learning models were developed: random forest (RF), deep neural net (DNN) and gradient boosted decision tree (GBDT). Demographics, time of day, presenting complaints, disease severity (triage category, arrival mode, referral status, vital signs, blood tests), administration of ECG and other scans, treating specialty and ED location were used as covariates in the modelling. 

Results 

We included 139,557 ED patients of whom 56,630 (41%) were hospitalized.We split the data in a train and test set (2/3 train, 1/3 test). The AUC of the conventional multivariable logistic regression model was 0.833 (95%-CI: 0.828-0.837), slightly higher than that of the RF 0.828 (0.823-0.833). The remaining machine learning models had the highest AUC: GBDT 0.843 (0.838-0.847) and DNN 0.861 (0.858-0.864) respectively.

Conclusion 

In our sample of ED patients, the DNN performed best compared with the conventional logistic regression and tree-based machine learning methods. However, differences between models were relatively small. Future studies should point out whether larger sample sizes will improve the discriminative performance of the machine learning techniques and which model could best be implemented in clinical practice.

Anne DE HOND (Leiden, The Netherlands), Laurens SCHINKELSHOEK, Menno GAAKEER, Ewoud TER AVEST, Ozcan SIR, Heleen LAMEIJER, Roger HESSELS, Resi REIJNEN, Evert DE JONGE, Ewout STEYERBERG, Christian NICKEL, Bas DE GROOT
00:00 - 00:00 #22697 - Major equestrian trauma in children: review of regional data and the Haddon matrix as an assessment tool.
Major equestrian trauma in children: review of regional data and the Haddon matrix as an assessment tool.

Introduction

In young girls horse-riding is one of the most common sports injuries. It is considered as one of the most dangerous sports with the severity of injuries comparable to motoring incidents. Since 2010 there have been 3,700 horse related incidents and 43 deaths in the UK on roads alone. A thorough and focussed history is likely to identify and help eliminate factors which contribute to an injury occurring and its severity, like wearing protective gear. A Haddon matrix, four by three grid, provides a structured approach to gather relevant information. The three rows represent different phases of an injury (pre-event, event, and post-event), and the four columns represent different influencing factors (host, agent/vehicle, physical environment, social environment).

Method

We populated a Haddon matrix for horse related injuries in children with possible avoidable/protective factors that are essential to explore when history-taking. 29 cases of horse-related injury with an ISS (injury severity score) of greater than 4 attending a regional trauma centre were extracted from the national TARN (trauma audit & research network) database, covering the last 15 years. Electronic patient records date back 5 years so 10/29 cases were included. The Haddon matrix was applied to these 10 cases and assessed for the quality of information documented.

Results

These 10 children were aged between 3 and 15 years, 80% were female, 60% were transferred from another hospital and one later had a further horse-related admission. Only 4/10 cases documented whether protective equipment was worn. Of these four cases 3/4 children were said to be wearing helmets and 2/4 wearing body protection. Most of the injuries were sustained by a child falling off whilst horse-riding. However, 3/10 cases involved children being kicked by a horse, none of these 3 cases mention any protective equipment whilst around the animal or the level of supervision they were receiving despite their age being less than 6 years. Only 1/10 cases filled 50% of the matrix or more (6+/12 boxes). 5/10 children expressed interest in continuing to work with horses after their injury.

Conclusion and recommendation

Identification of injuries related to equestrian activities was limited to the most severe cases as only these are captured by TARN. Even in those cases, the history documented in the patients’ records often omitted important information which may help to identify injury modifying factors. Therefore, questions relating to the environment, supervision, training and use of protective gear of children while around horses needs to be investigated better when children come into hospitals with horse-related injuries. These findings could inform changes to improve the safety of these and other children around horses in future. We propose use of the Haddon matrix as a structured tool for data collection and identification of injury modifying factors, similar to current guidance and advice in relation to children presenting with safeguarding concerns. Children presenting even with minor trauma related to equestrian activity are likely to benefit from this intervention. Further research as to the impact of intervention when attending the emergency department is required.

 

Marina AWADALLA (Cambridge, United Kingdom), Peter HEINZ, Roderick MACKENZIE
00:00 - 00:00 #23258 - Management of CAD by patients in first encounter.
Management of CAD by patients in first encounter.

Background:

Coronary Artery Disease (CAD) is one of the major causes of death. Evidence suggests that some preventive measures by patients in emergency phase can reduce the rate and risk of mortality. Thus, understanding the signs and risk factors of CAD from the patients’ perspective and their ways of dealing with this disease is of vital importance.

Objectives: This qualitative study aimed to explore the Iranian patients’ experiences about CAD and how they manage it in their first encounter.

Patients and Methods: This study was a grounded theory study conducted on 18 patients with CAD. The data were collected through semi-structured interviews. Initially, purposeful sampling was performed followed by maximum variety. Sampling continued until data saturation. Then, all the interviews were recorded and transcribed verbatim. After all, the data were analyzed by constant comparative analysis using MAXQUDA2010 software.

Results:

The themes manifested in this phase of disease included 1- "Invasion of Disease"  with subthemes of "warning signs" and "risk factors", 2- "Patients’ Primary Challenges" with subthemes of "doubting primary diagnosis and treatment", and feeling of being different from others", 3- "Psychological Issues" with subthemes of "mental preoccupation", "fear of death and surgical intervention", "stress due to recurrence",  and "anxiety and depression", 4- "Management Strategies" with subthemes of "seeking for information", "follow-up' , and "control measures".

Conclusions: Based on the results, physicians and nurses should focus on empowerment of patients by facilitating this process as well as by educating them with regards to dealing with CAD. Further, it is also essential for the mass media to educate the public on how to treat patients with CAD.

Hossein KARIMI MOONAGHI (Mashhad, Islamic Republic of Iran), Mohammad MOJALLI
00:00 - 00:00 #23018 - Mathematical estimation of victim severity distribution in nerve-agent mass casualty incidents.
Mathematical estimation of victim severity distribution in nerve-agent mass casualty incidents.

Introduction:

Recent events with public usage of chemical warfare agents have highlighted the importance of chemical disaster preparedness, to which resource estimation is paramount. Mathematical modeling systems for casualty estimation already exist for military purposes, as reported in the AMedP-7.5 and AMedP-8C publications. This methodology can be applied to the general population for victim estimation in a civilian chemical mass casualty incident. Sarin gas was used as an exemplary agent due to the large amount of available evidence for clinical course and treatment, based on human and animal exposures. 

Methods:

The AMedP-7.5 mathematical model and AMedP-8 victim profile for casualty distribution calculation were adapted for the general population using the methodology described originally by Crosier & Sommerville. Using the parameters obtained, severity estimations were assigned using the NATO Triage system which is divided in 3 main categories: T3 (= green) representing the least severe category, T2 (orange) representing moderatly injured victims and T1 (= red) representing severely injured victims. Triage was assumed to take place in between 30 and 90 minutes after exposure, using signs and symptoms expected during this period. Untreated victims with lethal injuries are presumed to have died in this period.

Victims triaged as T1 are severely injured and require airway management and antidote treatment, while T2 victims are able to support their own breathing. T3 victims mainly have ocular symptoms and slightly to no respiratory compromise. Three exposure levels were selected for further analysis, representing mild, moderate and severe exposures, adapted from AMedP-7.5. These exposure levels assume a normal sized, healthy adult of 70kg.

Results:

Calculated exposure values were 0.81, 16.9 and 22.3 mg.min.m-3 for mild, moderate and severe exposures respectively. Mild exposures will result in 18.1% unaffected individuals and 81.9% T3 victims, having no T2 or T1 victims. Moderate exposures will result in 0.3% T3 victims, 84.2% T2 victims, 8.5% T1 victims and 7.0% deaths on site. Severe exposures will result in no T3 victims, 59.1 T2 victims, 16.4% T1 victims and 24.4% deaths on site.

Discussion:

Hospital capacity estimation is usually based on an assumed relationship between T1, T2 and T3 victims, based on earlier experiences in traumatic mass casualty incidents. A commonly cited distribution in Belgium is 1-2-4, meaning 4 T3s and 2 T2s for every T1 victim. This mathematical modeling exercise casts doubts on the applicability of these rules-of-thumb and suggest the need for flexibility.

While in this exercise Sarin was used as the principal chemical agent, other agents can be modeled by adapting the parameters. This approach uses a one-size-fits-all approach and assumes equal effects of the same exposure throughout the population. Caution should be used when extrapolating these results to selected populations such as children or elderly, as they are assumed to be more severely affected.

Conclusion:

Victim severity distribution during chemical incidents can vary from a large percentage of mildly intoxicated victims, to a high number of victims requiring intensive treatment, depending on their intoxication level. Hospitals should prepare for both extremes in their hospital disaster plan.

Dr Ruben DE ROUCK (Brussels, Belgium), Michel DEBACKER, Ives HUBLOUE
00:00 - 00:00 #23497 - Medical clearance of patients presenting with mental health problems to the emergency department since moving to a purpose built new emergency department location.
Medical clearance of patients presenting with mental health problems to the emergency department since moving to a purpose built new emergency department location.

Mental health patients represent an increasing proportion of presentations to our large city based emergency department (ED). This audit follows a sequence of audits that have been produced in our department assessing quality of physical care in mental health patients. Since our most recent audit, we have relocated to a newly re-structured ED. We aim to review the quality of care following this change.

 

We have focused on the adherence to the current pathway for medical clearance of mental health patientsprior to referral to the mental health team. This is currently a two- stage pathway. In the first stage, all patients are assessed regarding suitability for direct referral to the mental health team. If unsuitable, patients undergo a second stage of assessment in which they undergo full medical assessment by an ED clinician.

 

Based on previous audits, our aim isthat 100% of patients presenting with mental health problems to ED should be assessed using the Mental Health Integrated Care Pathway (MHICP) proforma, have full clinical observations (respiratory rate, oxygen saturations, pulse rate, blood pressure, temperature, GCS and pupil size), a urine dip, blood sugar level and a documented Mental State Examination (MSE). For those deemed unsuitable for the direct pathway, a further medical assessment is necessary and 100% of these patients should be seen by an ED clinician, have a documented full clinical history and a full physical examination. 

 

The Symphony audit tool was used to identify patients who presented to the ED at St Thomas’ Hospital with mental health complaints in between September-November 2019. A total of 1748 patients were identified. Patients were randomized and then data was collected from the first 20 appropriate consecutive patients from each week. A total of 123 patients were excluded due to incorrect coding.

 

Preliminary results reflect inadequacies in assessments prior to medical clearance. Only 40% of patients had the MHICP proforma completed. This is a reduction from 48% in 2017. No patients had a full set of observations. Only 6% of patients had their pupil check documented whereas compliance with performing the other observations was 80-90%. We will continue to review this data to assess overall quality of care in both the direct and indirect pathways used prior to medical clearance.

 

In order to address these already evident short fallings we will intervene with a 3-pronged approach. Firstly, we aim to organize targeted teaching sessions for senior staff such as nurses in charge. Secondly, we will influence decision makers such as high level trainee doctors. Finally, we will amend the MHICP proforma to prompt the documentation of assessments currently lacking, for example pupil check. We will then re-audit to assess the impact of our interventions.

Altan SYULEYMAN (London, United Kingdom), Catherine BROWN, Xiao Meng YE, Koorosh ALAGHMAND, Arjun THAUR, Victor COOKE, Shumontha DEV, Matt MAY, Jamal MORTAZAVI, Pippa ALAMANGO, Savvas PAPASAVVAS
00:00 - 00:00 #23730 - Minor head injury in the elderly: pertinence of head computed tomography in the emergency department.
Minor head injury in the elderly: pertinence of head computed tomography in the emergency department.

Introduction:

In this century, we have reached a progress in life expectancy, but it comes with an increase of elderly patients with several diseases, including head trauma. Despite the high prevalence of elderly, a few trials were interested in assessing the relevance of acts and congestion of emergencies departments (ED).

Goal: To study the epidemiological features of minor head injury and the pertinence of head computed tomography (CT) in elderly admitted in the ED.

Methods:

A retrospective observational study was conducted over four years. Inclusion of patients (age ≥ 65) admitted to ED for minor head trauma undergoing Computed tomography. The diagnosis of minor head injury was based on Glasgow Coma Scale (CGS).  The demographics, co-morbidities, clinical and biological data and in-hospital procedures were collected.

Results:
of 467 minor head trauma patients, 67 are aged over 65 years. Mean age 76± 8 years with sex-ratio of 1.48. Twenty-eight patients (42%) had a positive head CT: three (11 %) patients had an urgent neurosurgical indication and 25 patients (89 %) were send home.

The comparative study of positive head CT group versus negative head CT group N (%) (p value) has found :  male gender 18 (64) vs  21(54)  (NS), antiplatelet therapy 7(25) vs  3 (8) (0.04) , anticoagulant therapy 4 (14) vs 5(13)  (NS), initial loss of consciousness  22(79) vs  6(15)  (0.04), sub clavicular trauma 9(32) vs  14 (36)  (NS).

Conclusion:

It seems that the antiplatelet therapy and initial loss of consciousness are frequently associated with positive head CT in elderly patients.

Dr Fatma MEJRI (Ben Arous, Tunisia), Hana HEDHLI, Abdelaziz TAHER, Amel MAAREF, Brahim YOUSSEF, Montassar BHOURI, Aymen ZOUBLI, Rym HAMED
00:00 - 00:00 #23507 - Need for recovery amongst Emergency Physicians in the United Kingdom and Ireland: a Trainee Emergency Research Network (TERN) survey study.
Need for recovery amongst Emergency Physicians in the United Kingdom and Ireland: a Trainee Emergency Research Network (TERN) survey study.

Background: Need for recovery (NFR) describes an individuals’ need to physically and psychologically recuperate following a period of work and can be measured using the validated 11-item NFR scale. Increased NFR has been reported to be associated with the development of occupational health complaints with effects likely to be cumulative over time. Currently experiencing a workforce challenge, strategies to determine and reduce NFR amongst Emergency Physicians may conceivably reduce rates of burnout, improve wellbeing and aid retention. The objective of this study was to determine the NFR among Emergency Physicians in the United Kingdom and Ireland and to identify characteristics associated with higher NFR scores.

Methods: This study adopted a cross-sectional electronic survey design targeting a representative sample for six weeks from the 3rd June 2019. All Emergency Physicians employed within 112 participating Emergency Department (ED) in the UK and Ireland were eligible. The survey was developed following a single centre feasibility study, a patient and public involvement consultation and adhered to the Checklist for Reporting Results of Internet E-surveys. The final participant survey included the NFR scale plus 44 additional items exploring demographic, occupational and self-perceived wellbeing characteristics. The number of positive responses to NFR items were summated into the NFR score, from 0, indicating lowest attainable NFR, to a maximum of 100. An additional single site survey gathered data on department-specific and workforce characteristics. 

The primary outcome was the NFR score. Descriptive statistics are presented along with findings of a multiple regression analysis to determine associations between NFR and relevant characteristics.

Results: The median NFR score for all 4247 eligible consented participants with a valid NFR score was 70.0 (95% CI: 65.5 to 74.5), with an IQR of 45.5 – 90.0. A linear regression model found significant associations between NFR score and the participant characteristics: clinical grade; gender; patient type and long-term health conditions or disabilities. After adjusting for these characteristics, the NFR score increased by 3.7 (95% CI: 0.3 to 7.1) and 6.43 (95% CI: 2.0 to 10.8) for those with difficulty obtaining requested study and annual leave, respectively. Increased percentage of out of hours (OOH) work increased NFR score linearly: 26-50% OOH = 5.7 (95% CI: 3.1 to 8.4); 51-75% OOH = 10.3 (95% CI: 7.6 to 13.0); 76-100% OOH = 14.5 (95% CI: 11.0 to 17.9).

Discussion and Conclusion: Higher NFR scores were observed among Emergency Physicians than reported in any other profession or population to date. Four non-modifiable demographic factors were noted to decrease NFR; clinical seniority at consultant level, male gender, absence of long-term health condition or disability and working in a paediatric only ED. Three modifiable occupational characteristics were identified associated with increasing NFR score; poor access to study and annual leave and proportion of out of hours work. These factors correlate with previous work and support the hypothesis that broader perceptions of job autonomy and control may be explicitly linked to wellbeing in healthcare. Future strategies to reduce fatigue and improve physician wellbeing and staff retention should target these modifiable characteristics.

Laura COTTEY (Plymouth, United Kingdom), Tom ROBERTS, Blair GRAHAM, Daniel HORNER, Kara STEVENS, Doyo ENKI, Mark D LYTTLE, Jos LATOUR
00:00 - 00:00 #23119 - Neuroprotection Bundle for intubated traumatic brain injuries (TBI) in Emergency Department.
Neuroprotection Bundle for intubated traumatic brain injuries (TBI) in Emergency Department.

Background

TBI is the leading cause of death and disability in children and adults ages 1 to 44. Each year about 2.5 million individuals suffer from this injury , of which 50,000 results in death. More than 80,000 of these will suffer permanent disability and undoutedly will lead to an increase in the financial burden on health systems. 

Every year Scottish hospitals on their own will see on average 150-300/100,000 per year of patients who sustained traumatic brain injuries . Out of those, third of patients will require Rapid Sequence Induction(RSI), and 65/100,000 will unfortunately die in the first year.

All these patients will be admitted through ED and given the severity and long-term consequences of brain injuries, ensuring consistent and high level of neuroprotection, is of vast importance.

Methods/Design

At the start, we performed a retrospective assessment of intubated TBIs presented to ED QEUH January 2018 -December 2018, using STAG data. Results were synthesized with a survey of clinical team who has experience in managing of intubated TBIs.

Then, an aide memoir incorporating a data capture sheet was created by the researcher after presenting the aforementioned clinical evidence, and was used after the staff group had been given refresher training in TBI management and had the document explained to them. The sheet had main 6 metrics and space to record additional information.

Prospective phase of QIP was based on Pan DO Study Act (PDSA)cycles with 6 weeks reviews, synchronized with post implementation survey of medical and nursing staff on the shopping floor.

A total of 20 patients were intubated and ventilated in ED secondary to isolated TBI from January 2018 till end of December 2018, with only 3 metrics been achieved on average.  The improvement in the performance of the team during the prospective phase of the study demonstrated that capture sheets increased compliance criteria up to 5 metrics reading.

  

Results/Summary

The existing method of treating TBI’s was underperforming consistently with no intervention to assist in correcting or improving the process.

We identified a need and successfully developed Neuroprotection Bundle for intubated TBIs. This enabled the user to follow a structured approach to care delivery without missing any stages of care.

Katerina KIMBERLEY (Glasgow, United Kingdom), Nicola LITTLEWOOD, Susan DAISLEY, Kevin MCAUKEY
00:00 - 00:00 #22890 - Optic Nerve Sheath Diameter Changes at High Altitude and in Acute Mountain Sickness: Meta-regression Analyses.
Optic Nerve Sheath Diameter Changes at High Altitude and in Acute Mountain Sickness: Meta-regression Analyses.

Background: Recent reviews have discussed pathophysiological changes in the central nervous system after exposure to high altitude, but none have systematically discussed the clinical significance of an increased optic nerve sheath diameter (ONSD), and it remains unclear whether ONSD changes are correlated with altitude or whether acute mountain sickness (AMS) directly affects the ONSD. Therefore, we performed a systematic review and meta-regression analyses to assess ONSD changes in high altitude in subjects with and without AMS.

Methods: Cochrane Library, EMBASE, Google Scholar, and PubMed were searched for articles published until October 18th, 2019. The definitions applied were high altitude: > 2500 m; AMS: Lake Louise Score (LLS) 3 with headache or AMS-C score 0.7. Outcome measures were comparison of the means of ONSD between sea level and high altitude, and between subjects with or without AMS. Meta-regressions of ONSD change were conducted for correlation with altitude and time spent at that altitude. Restricted cubic spline regression was used to evaluate non-linear trends. PROSPERO registration number is CRD42018110917.

Results: Seven studies with 228 participants comparing ONSD from sea level to high altitude, and five studies with 463 participants comparing subjects with or without AMS, were included. ONSD was found to increase by 0.15 mm per 1000 m after adjustment for time (95% Confidence Interval: 0.11 to 0.18; p < 0.01). Restricted cubic spline regression revealed an almost linear association between ONSD change and time within 2 days. ONSD was larger in subjects with AMS (mean difference = 0.47; 95% CI: 0.14 to 0.81; p = 0.01).

Discussion & Conclusions: Our analyses show ONSD changes are correlated with altitude. The currently available data suggest that although ONSD change may tend towards increase in subjects with AMS, but there are not enough data to show the statistically significant effect. Small study numbers indicated substantial bias and warrant more studies.

Tou-Yuan TSAI (Taiwan, Taiwan, China), Su YUNG-CHENG, Kar Mun CHEONG, Tu YU-KANG
00:00 - 00:00 #23237 - Parental administration of analgesia to children attending the emergency department with acutely painful conditions.
Parental administration of analgesia to children attending the emergency department with acutely painful conditions.

Background:Pain is the most common symptom in the emergency setting however acute pain management in children is often sub-optimal in the pre-hospital and emergency environment. There is a paucity in the research on parental administration of analgesia to children prior to arrival at the emergency department with the majority of the literature focusing on pain management by emergency medical services. Acute paediatic pain management has not commanded the same level of research compared to the adult population and recent studies have highlighted the need for high-level evidence and further research. The aim of this study was to describe the prevalence of pre-hospital analgesic administration by parents/guardians of children.

Methods:A prospective cross-sectional study was conducted between May 2019 and September 2019 in the EDs of Cork University Hosptial (CUH) and Mercy University Hospital (MUH). Systemic sampling was used to recruit a defined proportion of consecutively approached parents of children who met the inclusion criteria. The inclusion criteria was children between the ages of 6 months - 16 years, who were self-referred to the ED with an acutely painful condition. They were approached following ED triage and asked to complete an anonymous questionnaire using an electronic table provided by the research team. Data was collected on patient demographics (age/gender), cause of pain (i.e. injury/illness), pain score on ED arrival, analgesia adeministration prior to ED arrival, type and dose of analgesia administered, reasons why analgesia was not administered. Data was then exported to Microsoft Excel and analysed using SPSS software.

Results:Overall 400 parents/guardians completed this questionnaire. 189/400 (47%) of children received analgesia from their parents/guardians prior to arrival at the ED. Factors which were independently associated with increased parental administration of pain relief were having a pain score ≥5 (53.4% vs 29%, p<0.001), children with siblings (49.7% vs 35.3%,  p=0.03) and presenting No correlation was seen between administration of pain relief and age (p=0.804), gender (p=0.114), cause of pain (p=0.079) or site of pain (p=0.098). Analgesics administered included Calpol® (44%)Nurofen® (30 %)Paracetamol (14%)Ibuprofen (8 %). Overall, 211/400 (53%) children received no analgesia before attending ED. Reasons for parents not administering pain relief included: 30% (62/211) of parents did not think the child needed it, 19% (39/211) did not give pain relief because the accident did not happen at home, 16% (34/211) did not want to mask the presence of the pain, 9% (20/211) believed the hospital should give the medications, and  9% (18/211) were afraid it would be wrong/harmful.

Conclusions:This study has demonstrated that over 50% of children presenting to the ED, with acutely painful conditions, did not receive adequate or timely pain relief pre-ED arrival, causing avoidable suffering. Children were more likely to receive pain relief from parents/guardians if they: have siblings, had a pain score >5, present to ED <48 hours after the onset of pain. Parental misconceptions surrounding pain management are a major barrier to them administering pain relief. Further education is required to dispel these myths surrounding analgesia and improve the care to this population.

Tessa DALY (Cork, Ireland), Rory O' BRIEN, Adrian MURPHY
00:00 - 00:00 #22758 - Pilot study comparing ventilation modes during cpr with automated mechanical chest compression device.
Pilot study comparing ventilation modes during cpr with automated mechanical chest compression device.

Background

 

Current cardiopulmonary resuscitation (CPR) guidelines lack statements of appropriate mechanical ventilation if automated mechanical chest compression devices (AMCCDs) are used. Aim of this pilot study was to compare three common ventilation modes during CPR with AMCCD.

 

Methods

 

This randomised prospective pilot study was conducted at the Technical University Munich between 01.11.2017 and 12.12.2019. Patients suffering from an ongoing out-of-hospital cardiac arrest treated with an AMCCD and an endotracheal tube in place were included in the resuscitation room as long as the attending expected to continue with the resuscitation for another 15 minutes. Randomization assigned to the three groups “biphasic positive airway pressure with assisted spontaneous breathing” (BIPAP-ASB), “continuous positive airway pressure” (CPAP) and “volume-controlled ventilation” (VCV) using an Oxylog3000® (Drägerwerk AG & Co. KGaA, Lübeck, Germany). For safety reasons the treating team was allowed to change ventilation whenever clinically necessary. The primary outcome was the mean tidal volume (VT) during the study period. Secondary outcomes were mean minute volume (MV) and mean end-tidal CO2 (etCO2). Statistical analysis was done using R version 3.6.2. with Kruskal-Wallis-test and Mann-Whitney-U-test for post-hoc analysis.