Introduction

Triage seeks to bring order and rationale to a potentially chaotic clinical environment. The most widely practiced method of Emergency Department (ED) triage in Europe is the Manchester triage system (MTS) that was introduced in 1997. It is reported that “the validity of the MTS is moderate to good”, however it is our experience that too many Majors patients are assigned to category 3 and that clinical granularity is lost. With rising numbers of frail elderly patients attending the ED and the increasing frequency of access block, this lack of differentiation between ‘true’ category 3 patients and physiologically well ‘condition specific’ category 3 patients has become more clinically relevant.

Our new triage system combines a validated physiological early warning score (NEWS), clinical trigger systems (e.g. sepsis 6), condition specific fast track pathways (e.g. fractured neck of femur) and most importantly, the clinical gestalt of our nursing staff.

This system has been piloted and fully implemented in Glasgow Royal Infirmary ED (GRI-ED).

 

Methods

The new triage system commenced 1^st July 2017. The twelve-week study period started on 31^st July. Seasonal variation was removed by comparing the same three-month period in 2016.

Records of all attendances at EDs across NHS Greater Glasgow & Clyde were obtained from Trakcare (Intersystems 2014) during the study period.

 

Results

A total 47,335 patient attendances at GRI-ED were available for analysis.

Two 12 week sample groups were analysed (2016 n=23,660) (2017 n= 23,675)

The median number of patients seen per day in these periods was similar (257 versus 259 for 2016 and 2017 respectively).

More patients were assigned to triage categories 4 (12% pre and 42% post change) (p<0.001) and 5 (0.23% pre and 15% post) (p<0.001), while significantly fewer were assigned to categories 0 (13% pre and 1% post) (p<0.001), 2 (14% pre and 9% post) (p<0.001) and 3 (57% pre and 28% post change) (p<0.001).

Only category 1 remained relatively unchanged (2.7% pre and 3% post).

Interestingly, there was no overall difference in median time to first assessment between the two samples (71 minutes and 71 minutes in 2016 and 2017 respectively) (p = 0.377 by Wilcox test). However, there were significant changes in time to first assessment within each triage category, particularly category 3 (92 mins pre and 82 mins post)(p<0.001). There was no overall difference in median length of stay between the two samples (157 minutes pre and 159 minutes post) (p = 0.59), however the median length of stay increased in the lower triage categories: 4 (130 mins pre and 154 post) (p<0.001) and category 5 (69 mins pre and 127 mins post) (p<0.001).

Despite the absence of a significant change in median length of stay, a significant improvement in compliance with ‘the four-hour target’ (89.8% in 2016 period versus 93.1% in 2017 period) (p < 0.001). Importantly, admissions fell significantly, from 35% in 2016 to 32% in 2017 (p < 0.001).

 

Conclusion

This simplified triage system has empowered our nurses, improved compliance with the 4 hour target and reduced admissions. 

Background & aim statement

More than 90% of head injuries (HI) presenting to emergency departments (EDs) are minor HIs. Over-utilization of computed tomography (CT) scans in the ED results in exposure of patients to unnecessary radiation and increases health-care resource utilization, including patients’ length of stay (LOS) in the ED. Using recommendations of the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative with an aim to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was felt to be both achievable and meaningful by our stakeholder group.

 

Measures & design

Baseline CT scan rates for patients with HIs were determined through a local 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refinement and implementation of a Canadian CT-head Rule modified checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers (both medical and nursing). Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and patient’s ED LOS. Our balance measure was return visits to the ED within 72-hours for this patient population.

 

Evaluation/results

Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant ‘shift’ in the run chart of the weekly proportion of CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%) and 10.4% at 8 months (47.9% to 43.1%). ED LOS for HI patients decreased by 12 min (237min to 225min). 33% of total checklists were completed. There was no immediate increase in 72-hr return visits following implementation of our initiative, but a small increase of 0.16% was observed during the 8-month study period (4.0% vs 4.16%).

 

Discussion/impact

Our local QI initiative was successful in decreasing CT rates both in the short- and long-term for patients presenting with HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure ongoing sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests.

Background

Patients present to the emergency department (ED) with a variety of symptoms. The assessment of symptoms at presentation offers readily available information, which is of great importance for clinical workup and possibly for outcomes. The predictive power of certain individual symptoms, such as dyspnoea, is well known. However, research has mainly focused on the investigation of single chief complaints, neglecting the fact that patients usually present to the ED with more than one symptom. A recent study showed that the number of symptoms reported at triage was 2 median (range 0-25), with women reporting significantly more symptoms. Knowledge on combinations of symptoms has great potential in the process of risk stratification.

We therefore aimed to identify the most common combinations of symptoms in an all-comer ED population and to report their related outcomes, such as hospitalisation, admission to the intensive care unit (ICU), and mortality.

 

Methods

A consecutive sample of all patients presenting to the ED of the University Hospital Basel was included over a time course of 6 weeks. The presence of 35 predefined symptoms was systematically assessed upon presentation, by a dedicated study team asking patients whether or not the symptom was present at the very moment.

 

Results

3960 emergency patients (median age 51, 51.7% male) were included. Hospitalisation occurred in 1237 (31.2%), ICU admission in 219 (5.5%) of all cases, and 55 (1.4%) patients died during hospital stay. Out of 3733 patients with complete one-year follow-up, 215 (5.8%) died within one year of presentation. The three most frequent combinations of two symptoms were headache and dizziness in 281 (7.1%) patients, fatigue and weakness in 275 (6.9%) patients, and weakness and dizziness in 200 (5.1%) patients, respectively. As for combinations of more than two symptoms, weakness, fatigue and dizziness (n = 106, 2.7%), and weakness, fatigue, dizziness and headache (n = 62, 1.6%), were reported most frequently. Three combinations of two symptoms were found to be significantly associated with in-hospital mortality; fatigue and weakness (Odds ratio (OR) = 2.59), headache and weakness (OR = 3.31), fatigue and dizziness (OR = 2.94), whereas several combinations were predictive for the outcome of hospitalisation.

 

Discussion & Conclusions

Several combinations of symptoms are frequent at presentation to the ED. Nonspecific complaints, such as weakness and fatigue, are among the most frequently reported combinations of symptoms, and are associated with adverse outcomes. The higher the number of symptoms reported, the higher the prevalence of nonspecific complaints, making it harder to come up with a working diagnosis that leads to focused clinical workup. Systematically assessing symptoms may add valuable information on the prognosis and may therefore influence triage, work-up, and disposition.

No trial registration occurred. Study protocol was approved by the local ethics committee (236/13, www.eknz.ch). This study did not receive any specific funding.

Objectives

Delayed recognition is the major cause of disability and mortality in sepsis. Since sepsis is not only an ICU problem, we aimed to compare the performance of qSOFA, NEWS and SIRS for identifying patients with community-acquired sepsis in an all-comer emergency department (ED) cohort.

Methods

In this prospective observational study, we included all consecutive patients presenting to the ED over a period of 3 weeks. We excluded patients with end stage dementia, those with ongoing life support and patients who declined to participate. Vital parameters, mental status and triage category were recorded at the time of ED arrival by triage clinicians. Demographics, laboratory measurements, microbiology tests and outcome variables were obtained from the hospital’s electronic health record. We defined “suspicion of infection” as the start of a course of antibiotics in the ED or the draw of a microbiological test within 24 hours after ED presentation.

Two independent experts retrospectively assigned a gold-standard diagnosis of sepsis and septic shock according to Sepsis-3 criteria. Patients eligible for review had a sepsis-related ICD-10 code at discharge or positive blood cultures drawn within 24h after ED presentation.

We calculated the discriminative performance of the scores using receiver operator characteristic (ROC) curves with area under the curve (AUC) analysis for sepsis and septic shock. We tested performance criteria for various cut-offs. We used suspicion of infection as a control variable.

Results

2930 patients presented to the ED in the study period, of which 2523 (86.1%) were included in the final analysis. Suspicion of infection was found in 634 patients in the hospital database: antimicrobial therapy in the ED was given to 186 patients, and 592 underwent microbiological testing within 24 hours presentation. The chart abstraction resulted in 68 charts being reviewed, of which 6 patients were classified as sepsis and 10 as septic shock due to community-acquired infections. AUC for early sepsis or septic shock was 0.76 (95%CI 0.63-0.89) for qSOFA, 0.88 (95%CI 0.78-0.99) for SIRS and 0.90 (95%CI 0.84-0.95) for NEWS.

Conclusion

While qSOFA may serve as a valuable tool for the identification of increased risk of adverse outcomes, we found that it performed poorly as a screening tool for early identification of sepsis in the emergency department.

The study was registered at the local ethics committee (236/13, www.eknz.ch). We received no external funding for the realisation of the study.

Objectives: The objective was to compare the performance of “informal triage” with the Emergency Severity Index (ESI) in an all-comer emergency population.

Background: Triage remains one of the key-tasks in emergency patients. A reliable and valid triage is crucial to prevent unnecessary deaths, morbidity and waste of medical resources. The ESI is a well-established triage tool, used emergency departments across the US but also in Europe.

Triage tools are being discussed controversially. Mainly because they differentiate not well in lower acuity.

Patients at risk can be identified using a first clinical impression, also called “Informal Triage”. We wanted to assess whether “Informal Triage” can outperform ESI theoretically in terms of identifying critically ill patients and in predicting mortality. If useful, this simple tool could help to save resources.   

Methods: Prospective data of 7131 patients collected in the emergency departments of the university hospital of Basel, a tertiary-care university hospital. We assessed if informal triage could theoretically replace formal triage by registering data regarding the question “how ill does this patient look?” as rated by physicians. Our primary endpoint was in-hospital-mortality and 30 day-mortality. Other endpoints included admission to hospital and ICU-admission.

Results: During a time span of three weeks each in the years 2013, 2015 and 2017 we included a total number of 7’131 patients. A total of 293 patients with a missing ESI-Score or a lacking informal triage score were excluded. 6’858 patients could be analysed using a complete dataset.

The Area under the Curve (AUC) for 30d mortality rate was 82.8% with a confidence interval (CI) of 78.6%-86.9% for the informal triage by a senior doctor. The AUC of the ESI triage was 75.3% with a CI of 71.2%-79.5% (P-Value < 0.001).

We received similar results for hospitalization: AUC of informal triage 80.5%, (CI: 79.4-81.5%) and AUC of ESI-triage 77.7% (CI: 76.7-78.7%), (P-Value < 0.001), for ICU admission: AUC informal triage 84.0% (CI: 82.1%-85.9%) AUC of ESI-triage 81.5% (CI: 79.7%-83.4%), (P-Value = 0.018), as well as for the in hospital mortality rate: AUC informal triage 85.9% (CI: 81.9-89.9%), AUC of ESI-triage 81.6% (CI: 77.8-85.3%), (P-Value = 0.012).

Conclusions:

Triage by physician by first clinical impression (“informal triage”) was theoretically able to predict various outcomes more precise than the Emergency Severity Index.

Background

Nearly 10% of patients who are admitted to an acute hospital die during the course of their admission, many of whom will have passed through an Emergency Department (ED) along the way. Treating ED patients who are dying in the same way as those who have a reversible cause for their illness can not only be futile but also harmful and costly. The aim of this study was to assess the impact of a treatment limitation escalation plan (TELP) in improving care of patients approaching the end of life.

Method

Retrospective case note review of 300 consecutive in patient deaths was carried out to assign them to one of three cohorts:1. Had a DNACPR order only, 2. Had both a DNACPR and a TELP, or 3. Had neither. A power calculation indicated that a sample of 98 patients in each group was required. Case reviewers used the Structured Judgement Review Method to make a determination of occurance of non-beneficial intervention (NBI) or harm. A sample of 20% of the reviews were checked by a second reviewer for quality control and to generate a Kappa value. The primary outcome was to determine if there was a significant difference in the rate of harms between each cohort. Statistical analysis using Poisson regression and comparison of Incidence Rate Ratios was carried out. Limitations were the inability to blind the reviewers to cohort allocation and potential judgement bias of the author who was involved with development of the TELP.

Results

Case notes were available for 289 patients. Numbers of patients in the 3 cohorts decribed above were 155, 113 and 21 respectively. The 'neither DNACPR nor TELP' cohort therefore did not have sufficient numbers to report statistical significance. This is explained by the high number (93%) of patients who had a DNACPR order. Patients in cohorts 1 and 2 were found to be similar in terms of age distribution and ward where they died. Analysis showed significant difference in both the number of NBIs and harms occuring between the cohorts (p<0.01). This was true both for the rate occurring per 100 cases and the rate per 1000 bed days. Kappa scores were favourable for the 4 reviewers involved, ranging from 0.74 - 0.85.

Discussion

In this study we demonstrated that use of a TELP in addition to a standard DNACPR significantly reduced the frequency of NBIs and harms, therefore resulting in significantly better care for patients who are nearing the end of life. Other studies have confirmed a reduction in harms using a TELP. The incidence of NBIs, or under treatment of a patient's palliative care needs has also been well documented.

In the ED, we need to be aware of the high number of patients passing through our care who are nearing the end of life. Where appropriate, we should be putting a TELP in place, not just a DNACPR. 

Not applicable.

Introduction: Systematic care of patients after OHCA and developement of CAC is recommended by the guidelines, but important „contra“ argument is prolonged transport of often hemodynamicly unstable patients in limited prehospital emergency care.
Aim: To determine if prolonged primarily transport of patients after OHCA to regional CAC influence initial hemodynamic parameters after admission, mortality a neurological outcome.
Methods: Analysis from prospective OHCA Registry of regional CAC from 2013 to 2017. Data were divided into 2 datasets: 1) INSIDE - when CAC is the nearest hospital and 2) OUTSIDE - patients transfered to CAC, but in past  would be transferred to one of the 7 another closer hospitals in the region. We observed duration of transport, baseline characteristics ( age, gender, bystander CPR, ROSC, shockable rhythm, acute coronary syndromes (ACS), catecholamins administration during transfer), hemodynamic parameters on arrival to hospital (systolic BP, lactate, pH, SpO2, body temperature and initial doses of vasopressors and inotropics) and final outcomes (30-day/in-hospital mortality,  length of ICU stay, artificial ventilation days, 1 year CPC).
Results: 232 patients were enrolled after OHCA in years 2013 to 2017, 27 were excluded for insuficient data and 19 for secondary transfer to CAC. We analyzed 186 patients, 93 in both groups. We observed no differences in baseline characteristics in both groups: men (66,7% vs. 80,6%, p= 0.29), age (64,51±1.324 years vs. 61.25± 1.443 years , p= 0.1), shockable rhythm (65,6% vs. 74,2%, p= 0.26), bystander CPR (68,8% vs. 72%, p= 0.75), ROSC (median, IQR) :17 (11-26) min vs. 20 (15-30) minutes, p= 0.29, ACS ( 44,1% vs. 48,4%, p= 0.66) and catecholamine administration during tranfer (80% vs. 70%, p= 0.18). We observed no differences in initial hemodynamic parameters in time of  admission in both groups. Systolic blood pressure: (median,IQR): 103 (82-120) vs. 105(82-124)mm Hg, p= 0.6, serum lactate level (median,IQR): 4.6 (2-8.1) vs. 3.5 (2-6.75) mmo/l, p= 0.372, pH (median,IQR): 7.242 (7.122-7.322) vs. 7.286 (7.177-7.318), p=0.159, body temperature: (median,IQR): 35.95 (35.08-36.5) vs. 36 (35.5-36.5), p=0.218 and oxygen saturation (SpO2):(median,IQR): 95 (91-100) vs. 98 (94-100), p= 0.14.
We observed no differences in catecholamins dosages. Norepinephrine (7.54±+1.75 vs. 5.98±1.17 mcg/min), p= 0.46 and dobutamine ( 66.31±45.81 vs. 38.6±15.62 mcg/min),p=0.56. There was no significant difference in in-hospital/30-day mortality between groups ( 44.1% vs. 42.3%, p= 0.88). 1-year good neurological outcome (CPC 1,2) was identical ( 54,2% vs 54.2%, p= 0.999). Median of artificial ventilation duration was without significant difference: (median/IQR) 3 (1-8) vs.5 (1-7.75) days, p= 0.36 and median of lenght of ICU stay was without significant difference: (median/IQR) 6 (2-14.75) vs. 7 (3-12) days, p= 0.74.
Conclusion: Strategy of primary transport of patients after OHCA to CAC significantly prolonged time of transport, but didn´t affect hemodynamic parameters and outcome of patients.

Background: Ideally, prehospital advanced life support (ALS) should be preceded by good-quality bystander cardiopulmonary resuscitation including chest compressions (CCs). This study aimed to investigate how differently quality of bystander-performed CCs on emergency medical service (EMS) arrival and provision of ALS by EMS paramedics affect the outcomes of out-of-hospital cardiac arrests (OHCAs) receiving bystander CPR.

Methods: Prospective observational study with propensity-matched analyses was conducted in Ishikawa Prefecture, Japan during the period of 2012– 2016 after obtaining ethical approval from a local committee. Of 3.088 adult (≥8 years) OHCAs receiving bystander-performed CCs on EMS arrival, CC qualities were determined in 3,004 cases by two EMS personnel including at least one paramedic qualified for ALS on their arrival at the scene, according to the standard recommendations: depth (one-third of chest depth or >5 cm), rate (100–120), proper position and adequate decompression. When two EMS personnel judged all criteria to be met, the quality was recorded as adequate. Primary outcome measure was neurologically favourable one-year survival. Secondary outcomes were sustained (>20 min) return of spontaneous circulation (ROSC) and one-month survival. After analysing the effects of good-quality CCs and ALS on outcomes and their interaction using a stepwise multivariable regression in all 3,004 OHCAs, propensity-matching procedures were applied for CC quality and ALS provision. Propensity-matchings and stepwise multiple regression analyses included CC quality, ALS provision, time intervals, backgrounds and characteristics of OHCAs.

Results: When analysed for all OHCAs, prehospital ALS (adjusted OR, 1.60; 95%CI, 1.28–1.99) but not good-quality of bystander-performed CCs was associated with sustained ROSC. Neither prehospital ALS nor good-quality CCs affected one-month survival. However, good-quality of bystander-performed CCs (3.33, 1.31–14.9) was associated with higher chances of neurologically favourable one-year survival, whereas prehospital ALS (0.20; 0.04–0.52) was associated with lower chances of the survival. There was no considerable interaction between good-quality CCs and prehospital ALS in any outcome measure. Propensity-matched analyses in CC quality- and ALS provision-matched pairs confirmed these findings. The incidence of sustained ROSC in cases with ALS provision was considerably higher than that without ALS provision for ALS provision-propensity-matched pair (N = 968 each, 29.0 vs 24.7 %, 1.32; 1.07–1.64) The rate of neurologically favourable one-year survival in cases receiving good-quality CCs was considerably higher than that receiving poor quality for CC quality-matched pair (N = 636 each, 3.8 vs 1.6 %, 2.81; 1.29–6.59). However, the rate of neurologically favourable survival in cases with ALS provision was lower than that without ALS provision for ALS provision-matched pair (N = 968 each, 1.5 vs 5.1%, 0.20; 0.10–0.39). The rate of 1-M survival did not considerably differ between the two groups in CC quality- or ALS provision-matched pair. Stepwise multivariable analyses for CC quality- and ALS provision-matched pairs revealed that witness status and initial ECG rhythm are other common and major factors associated with the outcomes.

Conclusions: Quality of bystander-performed CCs but not prehospital ALS provision is essential for neurologically favourable survival. Every effort should be made in a commuty to improve the quality of CCs before EMS arrival.

Objectives

Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. While patients requiring more shocks may be expected to have worse outcomes, the prognostic implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital defibrillations delivered and resuscitation outcomes (survival to hospital discharge and prehospital return of spontaneous circulation [ROSC]) among patients in OHCA.

Methods

Adult patients with an initial shockable rhythm over a 5 year period were included from registry of OHCA in Montreal, Canada. In order to ensure that this analysis would be immediately applicable, the relationship between the number of prehospital defibrillations delivered and the probability of both resuscitation outcomes was first analyzed in a way to reflect the dynamic nature of clinical decision-making such that each level of analysis represents the likelihood of the resuscitation outcome up to that number of shocks. For the alternative analysis, patients were separated in two groups according to the number of prehospital defibrillations they received: less than three or at least three. Resuscitation outcomes (survival to hospital discharge and prehospital ROSC) of the patients included in these two groups were compared using Pearson’s chi-squared tests. In addition, a multivariable logistic regression model was planned using a standard approach adjusting for pertinent variables to assess the independent association between the number of prehospital defibrillations administered and the resuscitation outcomes.

Results

A total of 1788 patients were included in this analysis, of whom 583 (33%) survived to hospital discharge. The probability of survival was highest with at the first defibrillation (33% [95% confidence interval {CI} 30-35%]), but decreased to 8% (95% CI 4-13%) following nine defibrillations. The same is observed for the probability of prehospital ROSC, which begins at 54% (95% CI 51-56%) and lowers to 24% (95% CI 18-30%) following nine defibrillations. Patients having received three defibrillations or more (median number of prehospital defibrillations: 5 [Q1-Q3: 4-8]) were less likely to survive to hospital discharge (22 vs 41%, odds ratio [OR] =0.41 [95% CI 0.33-0.50], p<0,001) and to experience prehospital ROSC (40 vs 64%, OR=0.38 [95% CI 0.31-0.46], p<0,001) than their counterparts (median number of prehospital defibrillations: 1 [Q1-Q3: 1-2]). In multivariable logistic regression models, a higher number of prehospital defibrillations received was independently associated with lower odds of survival (adjusted odds ratio [AOR] = 0.88 [95% CI 0.85-0.92], p<0.001) and with lower odds of prehospital ROSC (AOR=0.85 [95% CI 0.82-0.88], p<0.001).

Conclusions

For patients with OHCA with an initial shockable rhythm, requiring more defibrillations is independently associated with worse outcomes. Despite that requiring more defibrillations is independently associated with worst outcomes in that population, there does not seem to be an evident cut-off that would predict bad resuscitation outcomes and the number of shocks received should not influence treatment decisions alone.

This project received funding from the ‘Fonds des Urgentistes de l’Hôpital du Sacré-Cœur de Montréal’ and the ‘Département de médecine familiale et de médecine d’urgence de l’Université de Montréal’.

Objective: Delirium is a frequent problem among older patients in the Emergency Department (ED) and early detection is important to prevent its associated adverse outcomes. Several screening tools for delirium have been proposed for the ED, such as the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). Previous validation of this tool for use in the ED showed varying results, possibly because they were administered at different or unknown time points. The aim was to study incidence of delirium in older (≥70 years) ED patients using the CAM-ICU.
Methods: Prospective cohort study, in one tertiary care and one secondary care hospital in the Netherlands. Patients aged 70-years and older attending the ED were included. Delirium screening was performed within 1 hour after ED registration using the CAM-ICU. The 6-Item Cognitive Impairment Test (6-CIT) was determined for comparison, using a cut-off point of  ≥14 points indicating possible delirium, which has previously associated with the presence of delirium using gold standard assessment.
Results: A total of 997 patients were included in the study, with a median age of 78 years (interquartile range 74-84). Delirium as assessed with CAM-ICU was positive in only 13 (1.3%) patients. 95 (9.5%) patients had 6-CIT ≥14.
Conclusions: We found a delirium incidence of 1.3% using the CAM-ICU, which was much lower than the expected incidence of around 10% as been frequently reported in literature and what we find when using the 6-CIT. Based on these results, caution is warranted to use the CAM-ICU for early screening in the ED.

This work was supported by the Netherlands Organisation for Health Research and Development (ZonMW project number 62700.4001).

BACKGROUND

Elderly increasingly demand emergency department (ED) care, leading  to crowding.  ED visits have a profound impact on older patients, including high risks of adverse outcomes and loss of independency. The objective of this study was to evaluate  opinions of patients,  caregivers,  general practitioners (GPs)  and ED physicians (EPs) on the preventability of ED visits by older patients.
 
METHODS 

Prospective, observational and qualitative study of 200 patients of ≥70 years visiting a teaching hospital ED in the Netherlands between 24 July and 7 September 2017. Trauma-related visits were only included if a fall was involved. Semi-structured interviews were performed with patients, caregivers and GPs. EPs  were provided with written surveys. Patient data was extracted to determine vulnerability. Primary outcome was the opinion of patients and healthcare providers. Secondary outcomes were consensus on preventability and the qualitative data derived from the interviews. Mann-Whitney U and chi-square tests were used for continuous and categorical variables, respectively. Cohen’s kappa (κ) was used to measure agreement of preventability assessments.
 
RESULTS 

The mean age of patients was 79.6 years, 49.5% was male. The majority of (95%) lived independently before the ED visit; only half the patients reported any form of domiciliary care (51.4%) or a caregiver (50%). Patients deemed 12.2% of visits potentially preventable; caregivers 9%, GPs 20.7% and EPs 31.2%. Consensus on preventability was poor, especially between patients and professionals. Whilst patients most frequently blamed themselves; healthcare providers predominantly mentioned lack of communication and organizational issues as contributing factors.
 

DISCUSSION AND CONCLUSION

Despite being fragile, older patients who visit the ED in the Netherlands usually live independently and have a caregiver in only 50% of the cases. This is the first study to provide insight in the preventability of ED visits in the elderly according to patients, their caregivers, GPs and EPs. Patients consider an ED visit preventable less frequently than professionals. Little consensus was found between patients and healthcare providers, and the perspectives on contributing factors to a preventable visit differ between groups. In order to help improve geriatric ED care, future studies should focus on why these perspectives are so different and aim to align these.

Background:

Providing healthcare services within the care home environment is the most desirable option for care home residents.Advanced care planning tools, such as Anticipatory Care Plans (ACPs) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documents, help to provide patient-centred care in this setting. General practitioners (GPs) play a central role in facilitating this care and assessing when transfer to a higher level of care is required. In Aberdeen, the emergency department (ED) provides a medical decision support service for community practitioners through a dedicated phone line. Due to concerns raised by ED staff about the circumstances in which some care home patients were presenting to the ED this audit was primarily designed to review whether advanced care planning tools are being utilised for this patient group. Secondary aims were to understand more about the assessment of care home patients prior to transfer to ED and about their journey through the department.

 

Method:

This was a retrospective audit of routine clinical data extracted from the data management system Trakcare for the 112 care home patients who presented to the Aberdeen Royal Infirmary ED in January and February 2017 from Aberdeen city and Aberdeenshire. Further data was extracted from the ED documentation stored electronically on C-Cube. The audit was registered with the NHS Grampian Clinical Effectiveness Team (ProjID 3866) and ethics approval was not needed. The descriptive data was used to assess the availability of a DNACPRdecision or ACP in the ED, time of admission, reason for admission, duration of stay, and assessment prior to hospital transfer.

 

Results:

Analysis of the data showed that a DNACPR decision was available for 55% of patients and an ACP for 28% of patients. A third of patients had been discussed with or reviewed by a GP prior to hospital transfer and documented use of the ED decision-support service was found in 9% of transfers. Traumatic presentations accounted for the majority of transfers, there were equivalent numbers of presentations in and out of hours and 55% of patients were admitted to the hospital.

 

Discussion & Conclusions:

At a national level there has been considerable activity around advanced care planning and the national Guidance for Health and Care Professionals (2017) recommends that living in a care home should trigger the creation of an ACP. The results of this audit draw attention to an area for improvement in the advanced care planning processes for care home residents in Aberdeenshire. The audit results also highlight that consideration must be given to the barriers to unscheduled GP review for care home patients. Similarly, the infrequent use of the ED decision support service raises questions about how this service can be optimised. Inappropriate transfers to hospital are likely to be reduced by more widespread use of advanced care planning tools and increasing the percentage of care home patients reviewed by a GP prior to transfer to the ED. The result would be improved care for this patient group and more appropriate use of emergency services. 

NHS Grampian Clinical Effectiveness Team (ProjID 3866)

Background: The effect of hospitalisation in emergency department-based short-stay units (SSUs) has not been studied in older patients. We compared SSU-hospitalisation with standard care at an Internal Medicine Department (IMD) in acutely admitted older internal medicine patients.

Methods: We conducted a pragmatic randomised clinical trial. We randomly assigned patients aged 75 years or older, acutely admitted for an internal medicine disease, and assessed to be suitable for SSU-hospitalisation to SSU-hospitalisation or IMD-hospitalisation. SSU-hospitalisation was provided by a pragmatic ‘fast-track’-principle. The primary outcome was 90-day mortality. Secondary outcomes included adverse events, change in Lawton Instrumental Activities of Daily Living (iADL)-score within 90 days from admission, in-hospital length of stay, and unplanned readmissions within 30 days after discharge. All pre-planned analyses and interpretations were performed before the breaking of the randomisation code, but we included an evaluation of health care utilisation post-hoc (use and timing of diagnostic tests and treatments).

Results: Between January 2015 and October 2016, 430 participants were randomised (median age 84 years in both groups). Ninety-day mortality was 22 (11%) in the SSU-group and 32 (15%) in the IMD-group (OR 0.66; 95%CI 0.37-1.18; p=0.16). When comparing the SSU-group to the IMD-group, 16 (8%) vs. 45 (21%) experienced at least one adverse event (OR 0.31; 95%CI 0.17-0.56; p<0.001); 6 (3%) vs. 35 (20%) experienced a reduction in iADL score within 90 days from admission (p<0.001); median in-hospital length of stay was 73 hours [IQR 36-147] vs. 100 hours [IQR 47-169], (p<0.001), and 26 (13%) vs. 58 (29%) were readmitted (OR 0.37; 95%CI 0.22-0.61, p<0.001). Fewer tests and treatments were applied in the SSU-group, and the time to chest x-ray, CT scans, point-of-care ultrasound, and physiotherapy was significantly shorter.

Conclusions: Mortality at 90 days after admission was not significantly lower in the SSU group, but SSU-hospitalisation was associated with a lower risk of adverse events, less functional decline, fewer readmissions, and shorter hospital stay. SSU hospitalisation may be preferable in  acutely admitted older internal medicine patients.

Trial registration: NCT02395718 CS recieved a Ph.d. stipend from Region Zealand and University of Copenhagen for this work (13-53) CS recieved funding for this project from Region Zealand Research Foundation (12-000095)

Background:

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and specifically prevent unplanned ED readmissions, the URGENT care model was developed. The study aim was evaluating the effectiveness of the URGENT care model.

Methods:

A prospective single centre quasi-experimental study (sequential design with two cohorts, recruited from 1/12/2014 to 31/5/2015 and from 15/10/2015 to 31/5/2016, respectively) was conducted in the ED of University Hospitals Leuven. Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual ED care. Patient in the intervention cohort received the URGENT care model. The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. The interRAI ED Screener^© and clinical judgement of ED staff were used to identify patients at risk for unplanned ED readmission. A geriatric nurse was available during office hours to conduct CGA in at risk patients. Subsequently, a personalized interdisciplinary care plan was made. Discharged at risk patients were offered case manager follow-up. Hospitalized at risk patients received follow-up on a geriatric ward or by the inpatient geriatric consultation team if considered necessary. The effectiveness of the URGENT care model was measured primarily on 90-day unplanned ED readmission rate. Secondary outcome measures were hospitalization rate, ED length of stay (ED LOS), in-hospital length of stay, 90-day higher level of care, 90-day functional decline and 90-day mortality. The required sample size was 751 patients per cohort, making a total of 1502 patients. Cause-specific hazard-ratios, relative risks, logistic regression and a lognormal model were used when appropriate. In all analyses, a propensity model was used to handle the potential difference in patient mix between the cohorts. Bonferroni correction was applied if considered relevant.  

Results:

Unplanned ED readmission occurred in 170 of 768 (22.1%) control cohort (CC) patients and in 205 of 857 (23.9%) intervention cohort (IC) patients (P=.11). Statistically significant secondary outcomes were ED LOS (CC: 19.1 versus IC: 12.7 hours respectively; P=.0003), hospitalization rate (CC: 67.0% versus IC: 70.0%; P=.0.0026) and functional decline (CC: 21.5% versus IC: 26.6%; P=.0.023). ED LOS and hospitalization rate remained statistically significant after Bonferroni correction.

Conclusions:

The URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions.

 

Trial Registration: The study protocol was registered retrospectively with ISRCTN (ISCRCTN91449949). Funding: The (Flemish) government agency for Innovation by Science and Technology funded this study (file number: 135182). Ethical approval and informed consent: The Medical Ethics Committee of University Hospitals Leuven (B322201422910) approved this study.

Adherence to Geriatric Emergency Department guidelines in routine care

Introduction Older people visiting the emergency department (ED) are at risk of adverse outcomes. Since the number of older people presenting to EDs increases, there is growing interest in the complex health care needs of this patient group. Geriatric Emergency Department (GED) guidelines provide recommendations on how to improve care for these patients. The aim of this study was to describe adherence to GED guidelines for older ED patients.

Methodology This was a prospective observational cohort study including ED patients aged 70 years or older, during two months from 8am till 11pm. The following recommendations of the ACEP GED Guidelines were observed in a two-months inclusion period as a proxy for guideline adherence: use of urinary catheters, family presence, use of hospital bed instead of ED gurney and provision of food during ED stay. The degree of a stressful environment was measured by counting the number of involved care providers and the number of door movements of the treatment room.

Results In total 998 older patients visited the ED, of which 605 (60.6%) were observed during their ED stay. Urinary catheters were used in 6.8% of all older patients. For 88.8% of patients family was present, 35.6% of patients were nursed on a bed and 7.4% of patients received food during their ED visit. The mean number of involved care providers was 8 (SD=3.7) and the median number of door movements of the treatment room during ED treatment was 41 (IQR=24-62).

Conclusions Geriatric Emergency Department Guidelines adherence is low. The use of urinary catheters and presence of family in the ED seems good, but there is room for improvement of hospital bed use, presence of food and stressful environmental factors. To make sure that routine care follows guidelines, interventions such as education programs and environmental changes seem necessary.

During the conference this data will be compared with data after implementation of a system improvement program.

Background

 

Music has been shown to have a beneficial effect in patients with dementia for managing specific effects such as agitation, and improving communication. We hoped to demonstrate that using patient or carer selected playlists could improve the ED experience for patients with dementia and facilitate care.

 

Methods

 

We looked at a case series of consecutive patients presenting to the ED with a known diagnosis of dementia, who were displaying features of distress such as increased agitation. Music was delivered via an MP3 player with either headphones or a mini speaker depending on patient preference. Patients and/or carers selected a playlist of around 30 minutes. A number of musical genres including hymns, folk songs and others were available. The response was assessed using a simple evaluation tool with visual categories for mood assessment, and looking for presence of positive and negative behaviours and indicators such as smiling, eye contact etc.

 

38 “playlist episodes” in 24 patients were reviewed. Mood was scored from 1 (happy, represented by a smiling emoticon) to 3 (distressed, frowning emoticon) at the beginning and end of the playlist. Mood was assessed by the patient where they were able to communicate, or by carers. Witnessed behaviours were indicated by tick boxes, and carers were able to add comments if wished. 

 

Results

 

Of the 38 episodes, 2 had no post music score recorded. Average “mood score” prior to playlist for the completed 36 episodes was 1.842, post playlist was 1.054 (P value <0.00001). No patient was more distressed after than before, and the majority showed an improvement. A total of 86 positive behaviours and 5 negative behaviours were recorded. There were a number of positive comments from carers and family members.

 

No patients were recorded as refusing/unable to participate when music was offered.

 

Discussion

 

The fastest growth in ED attendances in the UK is for patients over 65. Studies report the incidence of cognitive impairment in these patients as between 21% and 40%. There is an increasing body of evidence that patients with dementia are vulnerable to adverse outcomes of hospitalisation. 

 

A review of behavioural disturbances in the ED showed that in elderly patients with cognitive impairment, behavioural disturbances were both more frequent and more severe. These patients have an increased risk of developing acute delirium while in the ED, and delirium has been shown to worsen outcome.

 

Music has been shown to be helpful in patients with dementia in a number of studies, including recently in the context of residential care, improving symptoms of depression and agitation. There are no reported negative consequences in the available literature.

 

Our study suggests that music can be beneficial in modifying the stressful experience of an ED attendance for these patients. It is easy to deliver, has no demonstrated adverse effects and involves minimal resource allocation or staff training. We intend to continue to use this intervention in our department and would recommend it to other EDs who manage patients with dementia.

With grateful thanks to www.playlistforlife.com who provided the MP3 player and initial music downloads

Background: The Bacterial meningitis score (BMS) accurately identifies children with pleocytosis at low or high risk of bacterial meningitis. To include new biomarkers (procalcitonin [PCT], C reactive protein [CRP]) may be helpful to design a more accurate decision support tool.

Objective: To design a more accurate decision support tool to distinguish bacterial from aseptic meningitis in children with cerebrospinal fluid pleocytosis.

Design/Methods: We carried out a multicenter, retrospective cohort study including children aged 29 days to 14 years who presented with cerebrospinal fluid pleocytosis at 25 Spanish participating emergency departments (ED) between 2011 and 2016 to develop a Meningitis Score for ED (MSE). We excluded critically ill patients, those non-previously healthy, those with purpura and those who had received antibiotics previously. To select the variables of the score we included those with an area under the RUC curve higher than 0.90; to select the optimal cut-off point we used the Youden index; finally, variables independently associated with bacterial meningitis were ranked according to the magnitude of the beta-coefficient.

Results: We included 819 children with pleocytosis (758 aseptic meningitis, 61 bacterial meningitis) The MSE was developed attributing 3 points for serum PCT (>1.2 ng/mL), 2 point for CSF protein (>80mg/dL) and 1 point for serum CRP (>40 mg/l) and CSF absolute neutrophil count (>1000 cells/mm3). The negative predictive value of a MSE value of 2 or higher for bacterial meningitis was 100% (95% CI 99.5-100; vs 99.3%; 95% CI 98.4-99.7% of a BMS value of 2 or higher). Of the 758 children diagnosed with aseptic meningitis, 639 had a MSE value = 0 (84.3%, 95% CI 81.5-86.7; vs 390, 51.4%, 95% CI 47.9-55.1% children with BMS=0).

Conclusion(s): The MSE accurately distinguishes bacterial from aseptic meningitis in children with cerebrospinal fluid pleocytosis. To include PCT and CRP increases the performance of the BMS.

Background
Life threatening hemorrhage accounts for 40% of mortality in trauma patients worldwide. Trauma is therefore the leading cause of death in patients aged 1-44 and in both civilian and military setting the most common cause of preventable death. After bleeding control is achieved, volume loss has to be restored. The positive effect of early in hospital transfusion of blood or blood components in equal proportions (1:1:1) is already proven but the scientific proof for the efficacy in the prehospital setting is still absent as a result of lack of randomized control trials.

Objective
Prove that prehospital transfusion of blood products is safe and effective on patients with extensive blood loss

Methods
Four databases have been searched: CINAHL, Cochrane, EMBASE and Pubmed in the period 1988 till March 2018.  After manually removing duplicates 2573 articles were screened on title and abstract by at least 2 reviewers. Articles were excluded when complied with the following exclusion criteria: no blood or blood products administered, animal study, no prehospital setting and no original data. 240 articles were subsequently screened on full text. Finally, a total of 48 articles have been included. Data was analyzed by meta-analysis for mortality.

Results
There was no significant difference in total mortality OR 1.09, 95% CI  [0.89, 1.33] or 24-hour mortality OR 0.93; 95% CI [0.64, 1.34]  for patients who received prehospital blood products, compared to standard care with crystalloids. A total of 4739 patients were transfused and 3 of them developed a complication which was possible the result of the transfusion (0.07%). Thirteen included studies advice the use of fluid warmers before transfusion.

Conclusion
The administration of blood products in the prehospital environment is safe, seems feasible but proof of efficacy is lacking.  Blood products have to be administered in equal proportions and heated before transfusion to minimize the risk to worsen hypothermia. Larger and randomized studies are required to demonstrate a statistically significant effect of the use of combined use of blood products.

Background & Aims: Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent Emergency Department (ED) complaint and often causes significant anxiety in patients and clinicians. Accordingly, this study aimed to compare the administration of topical Phenylephrine with topical Tranexamic Acid (TXA) in management of epistaxis.

 Materials & Methods: This double-blind, randomized clinical trial was conducted on 120 patients with epistaxis referred to Imam-Khomeini University in Urmia, Iran. Patients who met the inclusion criteria, were randomly allocated into two intervention and control groups. Sixty patients in the intervention group received one pledget soaked with TXA for 10 minutes in each nasal cavity. Sixty patients in the control group received Phenylephrine 0.5% with the same way. The cessation of bleeding in ED were evaluated by 10 minutes after the administration of the above-mentioned drugs.

 Results: Nasal hemorrhage was stopped in 17 out of 60 patients of control group received Phenylephrine (28.3%) while in the intervention group received TXA, 40 out of 60 patients (66.7%) experienced the cessation of their nosebleed that the difference was clinically and statistically significant (P<0.001).

 

Conclusion: According to study results, topical application of injectable form of TXA (500mg/5mL) can be used as an ideal drug in management of epistaxis in prehospital and hospital settings and subsequently leads to a reduction of extra costs and length of stay in the EDs.

Background

Unlike traditional outpatient facilities, patients arrive at urgent care in a sporadic fashion, leading to peaks and troughs in patient volume, resulting in workflow challenges. On-line appointment scheduling systems have been proven successful in primary care and specialty clinics but have not been widely implemented in the urgent/acute care setting. We hypothesized that implementing an online appointment scheduling system at our urgent care clinic would reduce the variability of arrival times, reduce the initial surge at opening,  and decrease the arrival to bed and arrival to doctor times.

 

Methods

We performed a retrospective observational study and collected data on individual arrival times and arrival to bed and to doctor times on all visits to our urgent care facility over the course of a year. Our facility was open for 10 hours every day. At the midpoint of the year, we intervened with an online appointment scheduling tool. The pre-intervention period was June – Nov 2015 and the post-intervention period was Jan – June 2016. The variance was compared between pre- and post-intervention periods using robust tests for equality of variances and medians were compared using Wilcoxon rank-sum tests.

 

Results

There were a total of 6,804 visits in the pre-intervention period and 7,396 arrivals in the post-intervention period. 37.5% of patients seen at urgent care made an appointment through our online scheduler in the post-intervention period. The overall variance in the number of patients seen per hour was reduced by 3.7% after our intervention (p<0.01). We also observed a reduction in the proportion of the total patients who arrived in the first hour from a median of 20% [IQR: 15% - 24%] to 17% [14% - 22%] of total daily volume (p<0.005). Median arrival to bed time was reduced from 10 [3 - 34] to 9 [4 -24] minutes (p<0.01), and median arrival to doctor time was reduced from 28 [12 – 56] to 25 [12 – 44] minutes (p<0.001). Both arrival to bed and arrival to doctor times had reduced variance after our intervention, 35.5% and 27.3% respectively (both p<0.001). We also observed significant reductions in the percentage of patients waiting to be roomed in the first 15 minutes (p<0.001) and in the percentage of patients who had to wait longer than 30 minutes to be seen by a doctor (p<0.001).

 

Conclusion

The implementation of an online appointment scheduling system at urgent care can reduce the variation in patient arrival time, particularly during the first hour, and time between arrival to bed, and to doctor. Our intervention also led to significant reductions in the number of patients waiting to be seen and roomed. Although there is only a 3.75% reduction in variance in overall number of patients seen per hour, this observation follows a well-studied concept in the modeling of queuing systems; small reductions in variance can significantly improve flow through a system. 

Background  Diagnostic errors are frequent and have severe consequences. Most studies of the subjects however analyze cases of error only, making it difficult to identify case characteristics unique to diagnostic error. Our objective was to determine the rate of diagnostic error in patients hospitalized through the emergency room, identify factors predicting such errors, and their consequences.

Methods We collected data through a prospective observational study in one university-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or different according to a predefined scheme by two independent expert raters. A generalized linear mixed-effects model was used to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic error. We further assessed in-hospital mortality, length of hospital stay, and diagnostic error, defined as discrepancy between primary admittance and discharge diagnoses.

Results 755 consecutive patients were included, diagnostic error identified in 12.3% of cases. Diagnostic error was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; P=0.038; odds ratio 1.34; 95% confidence interval 1.02 to 1.76) and increased patient mortality (8 (8.60%) vs. 25(3.78%); P=0.007; odds ratio 3.94; 1.46 to 10.60) as compared to no error. A factor available at admittance that predicted diagnostic error was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (P<0.001;  odds ratio 2.71; 1.51 to 4.86).

Conclusions Discrepancies between the emergency room admittance diagnosis and the hospital discharge diagnosis occur in every ninth patient and are associated with increased in-hospital mortality. Diagnostic errors are not readily predictable by fixed patient or physician characteristics but seem to depend on context.

Patients who leave without being seen. Presenting complaints and length of stay – who leaves when?

Background: Patients visit emergency departments (ED) for various reasons. Some leave, before being seen by a doctor (left without being seen, LWBS). The rate can be as high as 10% [1]. Numbers in Germany are lower [2]. A large Canadian study showed, that patients LWBS are low-risk for short-term complications [3]. The present study looks at presenting complaints and length of time until patients leave the ED.

Methods: The study reviewed all patients who LWBS in a single-centre ED of a teaching-hospital for a period of one year (January – December 2017). LWBS cases were compared with the total number of ED presentations. For LWBS cases were further analysed for triage category according to Manchester Triage System (MTS) and length of stay as well as presenting complaints according to the Canadian Emergency Department Information Systems (CEDIS) Code [4].

Results:

38,614 patients presented in 2017 of which 1,027 patients LWBS (2.66%). 185 patients left before triage, 1 was in the red MTS category, 3 in the orange, 56 in the yellow, 647 in the green and 135 in the blue category. Median time until patients left were 171 minutes. The top five presenting complaints according to CEDIS were pain of the upper or lower extremities, abdominal pain, back pain, and injury of the upper extremity.

Discussion & Conclusions:

We present first data on patients that LWBS from Germany for a period of one year. Compared to international data, fewer patients leave our ED without being seen. The number of LWBS patients can be a quality indicator and should be monitored regularly. Of LWBS patients, the majority was triaged in the lower urgency categories. We conclude that monitoring of LWBS patients can provide valuable data on ED performance. While not all patients are patient enough to wait to be seen by a doctor our data suggest that most of these patients present with non-urgent complaints that can be treated in an outpatient setting without experiencing adverse events. This study did not receive any specific funding.

References: 1. Fayyaz J, Khursheed M, Mir MU, Mehmood A (2013) BMC Emerg Med.;13:1. doi: 10.1186/1471-227X-13-1

2. Harding U (2014) Anästh Intensivmed; 55:S10

3. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA (2011) BMJ;342:d2983

4. Greiner F, Brammen D, Kulla M, Walcher F, Erdmann B (2018) Med Klin Intensivmed Notfmed. 2018 Mar;113(2):115-123

This study did not receive any specific funding.

Background: Emergency department (ED) overcrowding is associated with increased waiting time, reduced patient satisfaction and decreased quality of care. Numerous validated scores are available to assess ED overcrowding. The Emergency Department Work Index (EDWIN) is the most established score quantifying the ED overcrowding. To our knowledge, there is no reported application of the EDWIN in a Swiss ED. Therefore, we assessed the applicability of the EDWIN in a Swiss ED and investigated further predictors for ED overcrowding.

Methods: In a retrospective analysis, we enrolled consecutively ED visits of a tertiary care hospital from December 1^st-31^st, 2016. The EDWIN combines the number of patients per triage level, number of emergency physicians, available treatment beds and patients waiting for in-house admission. The EDWIN was scaled from 0 to 1.5 as “active but manageable”, between 1.5 to 2.0 as “very busy but not overcrowded” and >2 as “extremely busy and severely overcrowded”. The median EDWIN per hour was defined as the first endpoint.  To investigate predictors for overcrowding we grouped the ED visits with an EDWIN ≤2 as not overcrowded and >2 as overcrowded and performed multivariable regression analysis.

Results: During December 2016, we calculated the EDWIN at every full hour, for 24 hours and during 31 days, in summary 744 EDWIN calculations were performed. The mean EDWIN per hour was 1.2 (standard deviation (SD) 0.6). In 527 calculations (70.8%), the EDWIN was active, 135 calculations (18.2%) showed a very busy ED and in 82 observations (11%), the ED severely overcrowded. In average, the ED was severely overcrowded 2.6 times per day. The highest EDWIN was reported on Saturdays (mean 1.6 (SD 0.8)) and Sundays (mean 1.3 (SD 0.8). During weekends, overcrowding was from 10 pm to 04 am, EDWIN ranged from 2.1 - 2.3. During the week the mean EDWIN ranged from 1.0 - 1.2. The reduced number of emergency physicians during night shifts (p<0.001), increased number of patients in the ED treatment area (p<0.001), patients waiting for referral to the ward (p<0.001), weekend periods (p<0.001) and the number of isolated ED patients due to infections (p=0.002) had a highly significant association with overcrowding. In case of overcrowding, the waiting time was prolonged (p=0.001)

Discussion & Conclusion: The EDWIN was easily applicable in a tertiary care Swiss ED, objectively displayed severely overcrowding during the weekend nights and was strongly associated with the number of available emergency shift physicians, number of patients in the ED treatment area, patients waiting for referral to the ward, weekend periods and the number of isolations. To leverage the ED overcrowding in future, the two most important steps are to increase the number of emergency physicians during night shifts and to optimize the referral time to the ward which is hospital dependent.

No trial registration because no patient data were involved. This study did not receive any specific funding. Ethical approval: not needed

Background

There is a lack of evidence on how travel distances and geography impact emergency department (ED) attendances, particularly non-urgent ED visits.  We investigated the impact of patient journey time to the ED on the probability of patients using the ED for non-urgent care that could have been provided elsewhere, such as in a primary care type setting.

Methods

We undertook a retrospective analysis of three years of Hospital Episode and Statistics Accident Emergency (HES A&E) data for one large region in England (April 1^st 2011 to March 31^st 2014).  Data was collected on all adult (>15 years) ED attendances in the region.  Patient journey time (in minutes) to ED was measured using Department of Transport data as the time to the nearest ED from the centre of the lower super output area (LSOA) that the patient resided in.

The relationship between non-urgent ED attendances and journey time to the ED was analysed initially and also examined by age categories (16-44, 45-74 years and 75+), time period of arrival (in hours versus out of hours; in hours defined as 08.00 to 18.00 Mon-Fri), arrival mode (self-referred versus ambulance) and geography (urban LSOAs versus rural LSOAs).   

We also modelled the impact of journey time to the ED on the odds of an attendance being non urgent, controlling for age and socioeconomic status using multi-variate logistic regression.  A validated process based definition of non-urgent ED attendance was refined for this study and applied to the data.  

Results

There were 3,667,601 first time attendances to EDs, of which 554,564 were defined as non-urgent (15.1%). Rates of non-urgent attendances fell with longer journey times to ED.  Patients within a one-minute journey time of the ED had a probability of a non-urgent attendance of around 22% compared with 11% if they resided 20 minutes away.  If a patient self-referred to ED, the rate of non-urgent attendance for those residing less than one minute was around 29%.   

The relationship between shorter journey times and higher rates of non-urgent attendance was more significant in younger age categories.  This age effect was particularly evident in non-urgent attendances arriving by ambulance.  A stronger relationship between journey time and non-urgent attendance also appeared between 18.00 and 08.00 at both the weekday and the weekend.

Multi-variate analysis showed the odds of a non-urgent attendance decreased significantly with increasing journey time to the ED.  For every minute further away from the ED the odds of a non-urgent attendance decreased by 2.5% (odds ratio: 0.976, 95% CI:0.976, 0.976); by 2% (OR= 0.981, 95% CI:0.980-0.982) for self-referred non-urgent attendances and 3% (OR= 0.973, 95% CI:0.972-0.974) for ambulance non-urgent attendances. 

Discussion and conclusions

Patient journey time is a significant factor in non-urgent use of the ED. There is evidence that patients ‘on the doorstep’ of an ED are using them for primary care type presentations.  Alternatives to the ED such as urgent care centres may need to be located near areas of high ED use.

 

No trial registration required as a non clinical study using routine data sources. Funding information: The research was funded by the NIHR CLAHRC Yorkshire and Humber. www.clahrc-yh.nihr.ac.uk NIHR CLAHRC YH Grant number IS-CLA-0113-10020

Background:

The NHS plan in 2000 stated that “by 2004 no one should be waiting more than four hours in Accident and Emergency from arrival to admission, transfer or discharge”.  This has become known as the four hour standard, with the target reduced to 98% in 2005 and 95% in 2010. 

More recently, performance has fallen dramatically, with proportion of patients achieving the standard 84.6% in March 2018 (76.4% for type 1 EDs).  In January 2017, Jeremy Hunt announced that the target would in future only apply to “urgent health problems” although there have been no further announcements on how this patient group would be defined or further implementations plans.

Aims: To identify how time spent in the Emergency Department (ED) varies for different cohorts of patients, those with urgent and non-urgent problems.

Methods:

Hospital Episode Statistics (HES) data for ED attendances across 18 EDs in Yorkshire and Humber from April 2011-March 2014 were retrospectively analysed.  Patients were divided into the following cohorts: non-urgent (patients retrospectively identified as first attendance, no investigations, treatments or referral that required type 1 ED facilities), urgent not admitted, urgent admitted. Total time in ED from arrival to admission, transfer or discharge was calculated for each cohort.

Results:

There were 3,736,541 ED attendances during the period studied.  Of these 565,687 (15.1%) were categorised as non-urgent, 1,163,014 (31.1%) were urgent admitted and 2,007,840 (53.7%) were urgent not admitted. 

The four hour standard was achieved for 98.5% of the non-urgent patients, 96.5% of the urgent not admitted patients and 84.4% of the urgent admitted patients.    The distribution of total time in ED was markedly different for each gorup - the median time in ED was 96 (IQR 54-148) minutes for the non-urgent patients, 130 (IQR 82-185) minutes for the urgent not admitted patients and 209 (IQR 149-237) minutes for the urgent admitted patients.  28.2% of the urgent admitted patients were admitted between 220-240 minutes, compared to 8.9% of the urgent not admitted patients and 3.7% of the non-urgent patients.

Discussion:

Our work demonstrates that there are markedly different distributions for time spent in ED for the three different groups of patients that we have identified. The large spike in time spent in the department just prior to four hours, that has been consistently reported with UK ED attendances, is most apparent for patients with urgent conditions being admitted to hospital. This data demonstrates that the main challenges for departments with regard to the four hour standard is for the sickest patients, the urgent admitted patients.  This may be due to a combination of late decisions by ED clinicians, issues transferring patients and inpatient bed availability.

The non-urgent attenders (who arguably did not need to attend the ED) left the department well within four hours.  This may be a perverse incentive of the four hour standard being applied to all ED patients and may be driving ED demand.   

Based on our data, taking non-urgent patients out of the reported target would not improve compliance with the target.

No trial registration required as a non clinical study using routine data sources. The research was funded by the NIHR CLAHRC Yorkshire and Humber. www.clahrc-yh.nihr.ac.uk NIHR CLAHRC YH Grant number IS-CLA-0113-10020.

Background: 

Negative workplace behavior, especially negative communication is a recognized problem in many organizations and is known to have serious impacts on workplace performance, productivity and personal wellbeing. Emergency Departments (ED) can be high stress environments in which communication and perceptions of respect between physicians and other staff may underlie individual functioning. We conducted a study to estimate the influence of incivility (ICV) among physicians in the ED.

Methods :

We assessed workplace incivility in the ED with an online survey. We focused on frequency, origin, reasons and situations where ICV was reported. To measure the levels and the potential influence of ICV on psychological safety, social stress and personal wellbeing we correlated our questionnaire to standard psychological scales. Statistical analysis included Students t-test, chi squared distribution and Pearson correlation coefficient.

Results:

We invited all seventy-seven ED physicians to participate in our survey. Among those that completed (n=50, 65%) the survey, 9% of ED physicians reported frequent (1/week) and 38% occasional (1/month) incidents of ICV. 28% of physicians reported experiencing ICV once per quarter and 21% reported a frequency of only once per year, no physician reported ICV on a daily basis (Fig. 1). Levels of ICV were significantly higher in interactions with specialists from outside then within the ED (p<0.01) (Fig. 2). ICV from nonsurgical specialties was higher than  from surgical (Fig. 3). Our findings showed a significant correlation between internal (within the ED team) ICV and psychological safety. To ED physicians internal ICV was associated with lower levels of psychological safety (p<0.01). ICV displayed from sources outside the ED team was not associated with psychological safety, but we found a significant influence of external ICV on personal irritability and reduced wellbeing (p<0.01).

Discussion & Conclusion:

The incidence of incivility was high among the ED physicians. Although this was a small sample, the association between workplace ICV and psychological safety, personal irritation as well personal comfort suggests that ICV may be an important variable underlying ED team performance. These findings further underscore the need to foster a culture of respect and good communication between departments, as levels of ICV were highest with physicians from outside the ED. Future research would benefit from examining strategies to prevent and reduce ICV and identify reasons for personal variation in perception of ICV. During critical situations and in general collaboration with specialists, awareness of ICV and countermeasures are important to avoid decreased performance and negative impact on staff and patient.

Background

In recent years a number of Emergency Departments (EDs) have closed, or been replaced by another facility such as an Urgent Care Centre. With further re-organisation of EDs expected, the ‘closED’ study aimed to provide research evidence to inform the public, NHS, and policymakers when considering local closures. Our study objective was to understand the impact of ED closure/downgrade on populations and emergency care providers, the first study to do so in England.

 

Methods

We undertook a controlled interrupted time series of monthly data assessing changes in the patterns of mortality in local populations, and changes in local emergency care service activity and performance, following the closure of Type 1 EDs in England. Data was sourced from the Office for National Statistics (ONS), Hospital Episode Statistics A&E, Hospital Episode Statistics Admitted Patient Care, and Ambulance service computer-assisted dispatch (CAD) records.

 

The resident catchment populations of five EDs which closed between 2009 and 2011 (Newark, Hemel Hempstead, Bishop Auckland, Hartlepool, Rochdale) were selected for analysis. Five control areas were also selected.

 

Main outcome measures

The primary outcome measures were ambulance service incident volumes and times, emergency and urgent care attendances at ED, emergency hospital admissions, mortality, and case fatality ratios.

 

Results

There was significant heterogeneity in the results for most of the outcome measures between sites, but the overall findings were:  evidence of an increase on average in total incidents attended by ambulance following 999 calls, and those categorised as potentially serious emergency incidents; no statistically reliable evidence of changes  in attendance at Emergency or Urgent Care services, or emergency hospital admissions; no statistically reliable evidence of any change in the number of deaths from a set of emergency conditions following the ED closure in any site, though on average there was a small increase in an indicator of the ‘risk of death’ in the closure sites when compared to the control areas.

 

Implications

In the five areas studied taken together, there was no statistically reliable evidence that the re-organisation of emergency care was associated with an increase in population mortality. This suggests that any negative effects caused by increased journey time to ED can be offset by other factors. For example, if other new services are introduced and care is more effective than it used to be, or if the care received at the now nearest hospital is more effective than that provided at the hospital where the ED closed. However, there may be implications of re-organisation for NHS emergency care providers, with ambulance services appearing to experience a greater burden.

NIHR (Health Services and Delivery Research programme)

BACKGROUND 

Benign paroxysmal positional vertigo (BPPV) is a common emergency presentation that requires specific knowledge and skills for the emergency physician. The traditional face-to-face (F2F) teaching of BPPV often entails significant time for both the teachers and learners. Blended learning (BL) has become a common teaching approach in graduate medical education with its advantages of reduced time and comparable efficacy, but has not been tested in the context of BPPV teaching to Emergency Medicine Residents (EMR). The primary aim of this study was to assess whether a BL approach would prove more effective than a F2F approach in the EMR education on the management of BPPV. The secondary aim was to gauge the resident opinion of each educational approach.

METHODOLOGY     

38 EMRs residents in the study were randomly allocated to either F2F or BL approach. They were all assessed before and after implementation of BPPV education.  Skills acquisition was measured through the performance of Dix-Hallpike maneuver (DH) and Canalith reposition maneuver (CR), rated 0 (worst) through 5 (perfect) by raters blinded to the study groups. Medical knowledge was assessed through a written examination comprising 20 multiple-choice questions (MCQs). A validated electronic questionnaire was sent to all study participants to assess their perceptions and self-perceived competence of BPPV with each educational approach.

RESULTS

The characteristics of the residents in the two study groups were similar. In both the F2F and the BL groups, there was clear improvement in the post-intervention scores in BPPV skills and medical knowledge. The DH and CR evaluations of BPPV skills showed a median difference of 0 (95% CI, -1 to 1). For MCQ, the mean improvement seen in F2F group was 0.1 higher than that of than seen in BL but the 95% CI (-1.2 to 1.4) crossed the null value. More residents preferred F2F approach over BL approach for teachings of BPPV.

CONCLUSION

The study results showed significant improvements in the medical knowledge and skills acquisition of BPPV with both F2F and BL education approaches.   Although the improvements were virtually identical, more residents favored the F2F approach over BL approach for learning BPPV.

NA

Background:

Shift work and disperse training location hinder emergency medicine (EM) residents networking, collaboration and resources sharing. In small country with small-scale EM residents training program, the challenge become more serious. In Taiwan, there are 97 first year EM residents in 39 training programs in 2016. Twenty-five programs have 2 or 3 new residents every year. Domestic and international networking is a critical issue to deal with. Emergency Medicine Resident Network (EMRN) was created to enhance resources sharing, networking between domestic and international EM residents by on-line and off-line activities. Its mission is to achieve EM residents excellence through diversity and collaboration.

 

Methods:

EMRN was launched in December 5, 2015 as a Facebook group platform. Daily sharing on EM topics by members are the core activity. Online theme experience sharing is hold annually. Diverse offline activities were host to facilitate networking. Resident lecture competition enhances the ability of precise, efficient communication skills. Video recording interview with EM physicians during medical conferences on EM related topics and broadcast on social media. Outreaching to international EM residents’ associations for idea and experience exchange. EMRN is currently operated by three attending physicians and four resident volunteers from three hospitals.

 

Results:

EMRN Facebook group has 2512 members from 28 countries including Taiwan, Hong Kong, United States, Malaysia, and Macau. There are 1617 posts, 2727 comments, and 41950 likes in the past two years. Two online theme sharing activities on topics of advises to young EM attending physicians and advices to first-year EM residents were hold in 2016 and 2017. More than 50 senior EM physicians shared their thoughts and experience. The content was collected into two e-handbooks after activities and been downloaded for more than 500 times. The first Taiwan EM residents lecture competition was hold in the 2017 Taiwan Society of Emergency Medicine (TSEM) Annual Conference and will be hold regularly in future TSEM Annual Conference. The first EMRN interview was host during 2016 ACEP SA with the President of Emergency Medicine Residents’ Association Dr. Alicia Kurtz at Las Vegas. The second EMRN interviews were host during 2017 ACEP SA and 17 emergency physicians from Taiwan and Hong Kong were interviewed at Washington DC.

 In February 2017, the idea and experience of EMRN was shared in the Hong Kong College of Emergency Medicine (HKCEM) Private Chapter meeting. This event bridged the connection between EMRN and HKCEM Young Fellows’ Chapter which lead to the first Hong Kong and Taiwan EM Residents Forum schedule be host in 2018 TSEM Annual Conference.

Discussion & Conclusions:

Networking, collaboration and resources sharing are key elements in residents training. EMRN facilitate the process by hosting on-line and off-line activities through social media platform. EMRN provide a model, especially for small-scale EM residents training programs, to connect domestic and international residents regardless of official or financial support.

INTRODUCTION

After the recent Ebola outbreak response in West Africa, the World Health Organization undertook an internal reform to improve the global health emergency workforce. However, while the presence of young doctors in humanitarian missions is increasing, most of them lack formal training before deployment. As studies reporting on the preparedness of health providers in low-resource settings remain predominantly narrative, the aim of this paper was to compare residents’ performance in a simulated high-resource vs a low-resource environment.

METHODS

This was a prospective study with a crossover design. Ten senior residents in Anaesthesia acted as lead physicians during the management of two identical postpartum haemorrhages in a high-resource scenario (HRS), which mirrored the operating theater (OT) of our tertiary teaching hospital, and in a low-resource scenario (LRS) that reflected an OT in a developing country equipped according to the basic international standards of anesthesia. Participants had no prior simulation experience, had never received training in crisis resource management and had no previous experience in humanitarian missions. The study was conducted over two days in April 2017; residents were randomly allocated into two intervention groups using assignment envelops. On the first day, five residents were exposed to HRS and then to LRS, while on the second day, the remaining five residents began first with LRS and followed with HRS. Before entering the study scenarios, residents attended a seminar on the management of postpartum hemorrhage and a simulation tutorial where the functioning of the simulation setting was presented. Participants were allowed a 15 minutes familiarisation with the final setting (without the patient) in both scenarios. The mannequin NOELLE® (S550 Maternal Simulator) was used in both cases and was operated by a simulator technician. All actors were trained to standardise their performances and give pre-established responses to resident’s actions or inactions.The coordination of actors to standardise responses was performed by another simulation instructor through a handheld radio. The scenario was based on a real-life case and the sequence of events and cues were reviewed for realism and timing by two experts anaesthesists with valuable experience in humanitarian missions with the international organization Médecins Sans Frontières. Both scenarios were played for a maximum of 20 minutes and before each, residents received a situational report with a detailed explanation of the context. The progression of all Residents’ performances was videotaped and their crisis-resource management skills rated by an external and independent evaluator using the validated Italian translation of the Ottawa Global Rating Scale.

RESULTS

Residents’ overall performance decreased in LRS (P< 0.05). Residents also displayed reduced leadership, problem solving, situational awareness, resource utilisation and communication skills (P< 0.05) in LRS compared to HRS.

CONCLUSION

This study suggests that senior residents’ resource management skills decrease when managing a critically-ill patient in a simulated low-resource scenario when compared to their usual workplace. Therefore, attention should be drawn to the potential implications that deploying unexperienced and untrained doctors in the field may have on the health of local populations.

 

 

 

None

Background: The medical faculty sixth grade studentship or the commonly used term internship and residency are the real preparation period for the medical profession. In the emergency medicine internship, students personally taking care of a patient for the first time, share the responsibility with EM assistants at the diagnosis and treatment stage of the disease.This situation can lead to anxiety and depression in physician candidates. The present study is the first study to investigate depression, anxiety, and stress levels of sixth-grade medical students before and after the EM internship.

Methods: This study was prospectively conducted on the medical faculty sixth grade students receiving EM internship between October 15, 2015, and June 01, 2016. The students were subjected to Beck depression, Beck anxiety, and DASS-42 tests on the first and last days of EM internship, and anxiety, depression, and stress scores were determined. The participants who accepted to be enrolled in the study were taken to a private room in the emergency department and the survey forms were completed with a face-to-face interview.

Results: 131 sixth-grade medical students who met the inclusion criteria were enrolled in the study. The mean Beck depression score was 10.15±6.11 on the first day of internship and 6.37±4.79 on the last day of internship. The difference was statistically significant (p<0.05). The mean Beck anxiety score was 9.02±7.25 on the first day of internship and 4.69±4.85 on the last day of internship. The difference in Beck Anxiety score was statistically significant (p<0.05). The mean DASS-42 scores were 23.91±14.35 on the first day and 15.31±12.13 on the last day. The difference was statistically significant (p<0.05)

Discussion & Conclusions: To our knowledge, this study is the first to investigate depression, anxiety, and stress levels of the medical faculty sixth grade students before and after EM internship. Sixth-grade medical students showed high scores on stress, anxiety, and depression scales before the EM internship, which is due to various reasons including changing social environment, physical environment, emotional state and change of mental–biological functions. The last day scores are decreased as a result of elimination of many factors that we think as a reason of this situation and by experiencing the good aspects of working in emergency departments.However, as many causative factors disappear at the end of the internship and also as they experience the benefits of the EM internship, these scores drop on the last day of the internship. 

Violence in the Emergency Department; A two Centre staff survey.

 

Background:

Violence in the Emergency Department is a common and well documented occurrence; however, little is known about the frequency of exposure and impact of violence on medical, nursing and allied health staff.

 

Objectives:

To examine prevalence and impact of violence in the Emergency Department on staff in two high turnover hospitals within Monash emergency medicine network, Casey and Dandenong Hospitals.

 

Method:

During two separate periods, of two-week duration: between 15.8.2016 - 28.8.2016 and 20.2.17 - 5.3.17, surveys were distributed to all staff of each Centre’s Emergency Department and were requested to complete them at the end of every shift.

Participants were asked to identify themselves by their shift time, the area of the department they were working in, and their role in the department.

They were then asked to record if and how many times they were abused, whether there was verbal abuse, physical violence and likely drug or alcohol intoxication.

The last section of the survey left room for staff to report if they had been physically or emotionally harmed and if they had provided any formal or informal reporting of the event.

Space was made for people to leave free text at the bottom of the document.

 

Results:

Responses were received from 214 staff at one site and 127 at the other. Of those, 127/362 (35%) of staff reported at least on incident of physical or verbal abuse during their shift, for a total of 234 incidents. Physical abuse made up 10% of all incidents of abuse, however there were only 2 reported incidents of harm, conversely, 44% of people reported being emotionally affected.

 

11% of events were perpetuated by someone accompanying the patients, and 40% of all events were felt by the reporting staff member to likely involve alcohol or other drugs.

 

Conclusion:

Physical and verbal abuse is a common experience amongst Emergency Department staff. Fortunately, physical harm appears to be quite rare, however care must be taken to look after the physical and mental well-being of all staff members.

 

Overall, HCPs surveyed had positive attitudes towards organ donation but there was a lack of knowledge particularly among non-intensive care professionals. This study highlights the need to increase awareness along with implementation of educational programmes among HCPs regarding organ donation and transplant.

Background:  According to the Drug Enforcement Administration, over 136 million hydrocodone prescriptions were dispensed in 2013, with approximately 24.4 million people over the age of 12 years using it for non-medical purposes. The non-medical use of hydrocodone among teenagers is common, with the National Institute on Drug Abuse reporting the past year use of Vicodin (hydrocodone/acetaminophen) among this population being 1 - 5%. According to the Monitoring the Future survey, the annual prevalence rates of Vicodin use were  0.7%, 1.5%, and 2.0% for 8^th, 10^th and 12^th graders respectively. This study examines the trends in hydrocodone exposures among teenagers reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all hydrocodone exposures in patients between 13 and 19 years from 2011 to 2017. We descriptively assessed the demographic and clinical characteristics. Trends in hydrocodone frequencies and rates (per 100,000 teenage exposures) were analyzed using Poisson regression. Percent changes from the first year of the study were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 18,097 teenage exposures to hydrocodone reported to the PCs from 2011 to 2017, with the number of calls decreasing from 3,051 to 2,167 during the study period. Among the overall hydrocodone calls, the proportion of calls from acute care hospitals and EDs increased from 55.2% to 71.6% from 2011 to 2017. Multiple substance hydrocodone exposures accounted for 55.8% of the overall calls and 73% of the calls from acute care hospitals and EDs. Approximately 13.8% of the patients reporting hydrocodone exposures were admitted to the critical care unit, with 20% being admitted to a psychiatric facility. Residence was the most common site of exposure (93.6%) and 67% of cases were enroute to the hospital via EMS when the PC was notified. Females were more frequently exposed to hydrocodone (63.8% of cases). Suspected suicide (36.7%) was the most common reason for exposure, with intentional abuse accounting for 12.1% of the cases. The proportion of suspected suicides (78.1%) was higher among cases reported by acute care hospitals and EDs, while abuse was less frequent (10.7%). Minor effects (34.1%) were the most prevalent among cases. There were 30 teenage deaths due to hydrocodone exposure, with 21 of them occurring in the hospital or ED setting. The most frequent co-occurring substances reported were benzodiazepines (12.3%), and Ibuprofen (10.4%). Tachycardia and vomiting were the most frequently demonstrated clinical effects. Naloxone was a reported therapy for 9.2% cases, with this therapy being performed prior to PC recommendation in most cases. Overall, teenage hydrocodone exposure calls decreased by 29% (95% CI: -32.8%, -24.9%; p<0.001), while the rate of such exposures decreased by 34.1% (95% CI: -38.6%, -29.3%; p<0.001).

Conclusions: PC data demonstrated a decreasing trend of hydrocodone exposures among teenagers, which may be attributed to the current decrease in opioid prescribing due to policy and practice changes. However, the increase in the proportion of calls from the acute-care hospitals and EDs indicates higher severity of such exposures, especially when multiple substances are involved.

N/A

Background: Asthma is one of the most chronic disorders of Respiratory System. Asthma Acute Attack Crisis control is a health problem in Emergency departments, worldwide. This trial focus on the fact that if B-type Natriuretic peptide, as a bronchodilator, can improve clinical and para clinical indexes of severe acute asthma attack or not.

Methods: In a randomized controlled clinical trial, 40 patients of severe acute asthma attack in the acute crisis were included in the study. The patients have been randomized to two case and control groups. The control group received severe asthma attack treatment consist of 3 doses of 2.5mg nebulized racemic albuterol and 0.5mg nebulized iprathropium bromide 0,20,40 minute after arrival. Also, a single dose of 50mg oral prednisolone prescribed at arrival. The case group received medication of control group as standard treatment plus intravenous B-type Natriuretic peptide 2microgram/kg bolus within 1 minute, followed by BNP infusion of 0.01 µg/kg/min for minutes 0-30, 0.02 µg/kg/min for minutes 31-60 and 0.03 µg/kg/min for minutes 61-90. Borg Dyspnea scal, FEV1 and PEFR were evaluated and recorded as investigated variables in the minutes 0, 30 ,60 ,90 after arrival. The trial sample size was calculated according to Phase I,II clinical trial sample size calculation standards; our study small sample size was a limitation for our trial. The case and control groups have been randomized via block randomization.

Results: Demographic features in terms of age (P=0.085), sex (P=0.752) and asthma duration (P=0.677) in both groups were similar. Clinical Borg dyspnea scale, FEV1, PEFR variables in both case and control groups in the minutes 0, 30, 60 and 90 after arrival did not make any significant differences(P>0.05). Finally, the severity of dyspnea was not different between the two groups at discharge (0.72 vs. 0.75, P=0.893).Hemodynamic parameters were not statistically different between case and control groups. There were no adverse effect, we could consider as known BNP side effects during the trial. 

Discussion and Conclusion: Our data showed no advantages of adjunctive administration of intravenous BNP infusion when it is added to acute severe asthma standard treatment. More study should be established to clarify the drug precise clinical influences. The small sample size of our study was an important limitation.

 

This Project has been directed with financial support of Ahvaz Jundishapur University of Medical sciences, Ahvaz, Iran. The Ethic Committee Approval code is: IR.AJUMS.REC.1394.234 The Project No. U-94070

Background: With the expanded use of smartphones, distracted driving has became a trauma public health issue. The objective of the present study is to evaluate the incidence and geographical disparities in distracted driving in Canada.

Methods: An iOS-based app was developed to allow volunteer users to observe driver behaviours at the roadside without limitation in space and time. Data were reverse-geocoded through Google Maps API, population densities were computed based on the Canada Post Forward Sorting Area (FSA; first 3 digits of postal code), and population by FSA from Statistics Canada and the area of the FSA was computed from a corresponding shapefile.

Results: A total of 24,572 drivers were observed. The overall incidence of distracted driving was 9.68%. Men and women were equally distracted while driving, whereas professional drivers were more distracted than drivers in personal vehicles (12.2 v. 9.4, OR 1.33). The incidence of distracted driving ranged from 4.75% in British Columbia, 7.7% in Ontario, 10.0% in Nova Scotia, 11.3% in Quebec and 11.8% in Manitoba to 15.2% in Alberta. There was a strong relationship between population density and distracted driving, with sparsely populated areas having much more distracted driving than urban areas. The incidence of distracted driving decreased from 22% in sparsely populated areas (25 ha/km2) to 6.6% in densely populated areas (100,000 ha/km2).

Conclusion: Distracted driving is a very frequent behaviour. In Canada, on average 1 out of 10 drivers is actually distracted while driving. There are significant geographical variations in distracted driving across Canada.