Background: Pain is a widespread problem, affecting both men and women; studies have shown that women in the emergency department (ED) receive analgesic medication and opioids less frequently in comparison with men.
Objective: The purpose of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender , and thereby to examine  the extent of gender discrimination in treating pain by  gender

Design: This is a single center retrospective cohort study which included 824 patients. As an acute pain model, we used renal colic, with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by visual analog scale (VAS) and number of VAS examinations. Time intervals were calculated between admissions to different stations in the ED. We recorded the number of analgesic drugs given, type of drugs prescribed and drug class (opioids or others).  

Results: A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity and laboratory findings. VAS assessments were higher in men than in women (6.43vs.5.90, p=0.001, respectively). More men than women received analgesics (68.8%vs.62.1%, p=0.04, respectively) and opioids were prescribed more often in men than in women (48.3%vs.35.7%, p=0.001). The number of drugs prescribed per patient was also higher in men compared to women (1.06vs.0.93, p=0.03).  A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.

Conclusion:  We have observed differences in pain management between genders which could be easily interpreted as gender discrimination. Yet, these differences might also be attributed to other factors which are not based on gender discrimination but rather on gender differences.

Clinical implication: The medical and paramedical staff should be made aware that women might experience and express pain differently from men and diagnostic methods and treatment may need to be adapted accordingly.  

none

Background: Arterial blood gas (ABG) analysis is integral to the assessment of critical illness, providing information on the etiology and severity of a disease process. Despite low rate of complications, the procedure can lead to major vascular damage such as thrombosis or pseudo aneurysm. Moreover, it is a painful procedure that can be challenging to perform. Due to the lack of evidence of benefit for the patient or the health care team of a venous blood gas rather than an arterial blood gas in the absence of suspicion of hypoxemia, arterial blood gas is currently the standard of care for the analysis of acid-base disorders. Indeed, among the university hospitals affiliated to the Paris Diderot University, 4 of the 5 emergency departments (ED) carry out ABG. Demonstration of the superiority of venous sample over arterial sample regarding pain could substantially modify current practices.

Objectives: The main objective of this study was to show the superiority of venous sampling in arterial sampling with respect to the patient's pain related to the collection of a blood gas in EDs.

Materials and methods: We performed a randomized multicenter prospective study that recruited from 4 emergency departments during two months period. Eligible patients were non-hypoxemic patients with an indication of ABG. The randomization and allocation were computer generated. The primary end-point was the average pain, in millimetres, according to a self-measurement (the Visual Analogue Scale), within 3 minutes of the blood sampling between the arterial puncture group and venous puncture group. The secondary end points were the convenience of the sampler, number of attempts needed to obtain a blood gas sample, number of different operators needed to obtain a blood gas sample and failure of the blood gas sampling procedure

Results: 113 patients were included: 55 in the control group and 58 in intervention group. The median [Q1;Q3] maximal pain felt by the patient within 3 minutes after the sampling, among the Visual Analogue Scale was respectively 40 [21;59] in arterial group and 18 [10.5;30] in venous group. The mean difference was 17.9 [CI95 9.6;26.3] (p<0.0001). The prescriber’s satisfaction in terms of diagnostic profitability of the blood gas did not differ between the two groups (p=0.25). Success on the first attempt was better in venous sampling: 93% (n=53) success versus 80% (n=44) in the arterial group (p=0.073). But the number of sampler change was the same in each arm (n=3, 5%). Almost half of sampler categorized the sampling as easy (n=24, 44%) or moderately easy (n=23, 41%) in the control group. Majority of sampler categorized the sampling as easy (n=30, 69%) or moderately easy (n=16, 28%) in the intervention group

Conclusion: Venous blood gas is less painful for patients, simpler for the health care team and provides sufficient biochemical information for the doctor in comparison with an ABG.

Trial registration: clinicaltrials.gov, NCT03784664. December, 24^th 2018

Trial registration: clinicaltrials.gov, NCT03784664. December, 24th 2018

Background: Intravenous morphine titration (IVMT) is the gold standard for opioid treatment in the Emergency Department (ED). Nebulized morphine titration (NMT) may represent an alternative without venous access. After a preclinical study on healthy volunteers, we test the hypothesis that NMT is at least as effective as IVMT to initially manage severe acute pain in the ED, supported by pharmacologic data. Methods/design: We designed a multicenter (10 French EDs), single-blind, randomized and placebo controlled trial (NCT03257319). Adults between 18 and 75 years with Visual Analog Scale (VAS) ≥ 70/100 or Numeric Rating Scale (NRS) ≥ 7/10 will be enrolled.  850 patients will be randomized in two groups to compare two routes of MT as long as VAS > 30 or NRS > 3. In group A (425), patients will receive an initial NMT during 5 to 25 minutes. In group B (425), patients will receive initial standardised IVMT.  NMT is defined as a minimum of one and a maximum of three 5-minute nebulized boluses of 10 mg or 15 mg (weight ≥ 60 kg), at 10-minute fixed intervals. IVMT is defined as a minimum of one and a maximum of six boluses of 2 mg or 3 mg (weight ≥ 60kg), at 5-minute fixed intervals. In both groups, after 25 min, routine IVMT will be continued until pain relief if necessary. The primary outcome is the rate of relief 1 hour from the start of drug administration. Complete pain relief in both groups will be compared ( non-inferiority design). Secondary outcomes are pain relief at 30 minutes and at 2 hours and median pain relief. We will compare final doses, and study the feasibility and tolerance of NMT (major and minor respiratory, hemodynamic or neurologic effects). In addition, we decided to perform a supplementary pharmacokinetic (PK) and pharmacodynamic (PD) study to assess the NMT characteristics. Thirty patients from group A will be included in a single-center analysis for a NMT modelling objective. Morphine, Morphine-3-betaglucuronide and Morphine-6-betaglucuronide will be measured at minimum 6 and maximum 7 study times (T0-T5-T10-T20-T30-T60-120). A intermediary PK/PD analysis at the tenth patient is provided. Results: The multicentre clinical study is still in progress. The PK/PD intermediary analysis shows that morphine concentration are therapeutic concentrations and are similar than the expected concentration with IVMT, for mean concentrations and dispersion (1-120 ng/mL, 4-19,5 ng/mL for the peak concentration). Metabolites ‘concentrations analysis suggest hepatic metabolism of morphine by this route of administration. Discussion and Conclusion: This trial is the first multicenter randomized and controlled NMT protocol for severe pain in the ED using the titration concept. We propose an original approach of combined titration with an endpoint at 1 hour and non-inferiority design supported by pharmacologic early data that have established the NMT relevance. The PK/PD NMT study highlights the possibility of future organisational improvements for MT access in the ED.

Current Controlled Trials NCT03257319, registered on 22nd August 2017 n° EudraCT : 2017-001638-24 PHRCN 2013

Background: Morphine Titration (MT) is the gold standard for severe acute pain management in the Emergency Department (ED) in France. Guidelines suggest its ubiquitous use for adults with Visual Analogue Scale (VAS) ≥60/100, or Numeric Rating Scale (NRS) >6/10 at admission. Despite recommendations oligoanalgesia remains problematic and opiate prescription is rare in the ED. Pain management by protocol at ED admission is presented as the best solution. However, physicians’ adherence to protocol, as bedside determinisms of prescription of morphine titration, is poorly investigated. Objectives: 1-Evaluate the prevalence of MT among eligible patients according to French guidelines. 2- Collect real-time data on the reasons for morphine non-titration (MNT) at the bedside, regarding patients, physicians and ED organisation. 3-Evaluate the adherence of physicians to MT protocol outside the care environment 4- Identify factors statistically associated with MNT. Methods: We conducted a 1-month single-centre cross-sectional study in our university ED, including patients with VAS≥60 (or NRS≥6) on initial nurse evaluation. We aimed to evaluate the prevalence of MT and to identify real MNT determinisms among 37 items (from preliminary focus groups and literature analysis). The data collected were divided into 6 subclasses: morphine contraindications, morphine non-indications, decision for other analgesic treatments, decision for reassessment of pain, opiophobia and other prescribing fears, care environment related-issues. In a simultaneous study, to estimate the ideal rate of MT, a real-time blind assessment of the records by non-prescribing senior physicians of the patient was performed. Then a 3-month case-control study was conducted to identify associated factors with MNT. A bivariate analysis was performed involving 8 variables: Age, gender, initial VAS/NRS levels, route of admission and discharge, diagnosis, prescriber’s gender and grade. Results: 164 patients (women 54.2%, mean age 45.9 years) were included in the cross-sectional study with mean VAS 75.5/100 (SD = 13.1). MT prevalence was 6.1% CI95% [2.4-9.8]. The three main reasons for MNT were: subjective physician-reduced VAS (45.7%), priorization for lower analgesic levels (33.5%) or for non-analgesic etiological treatment (12.8%). In the “blind reading” study, the ideal rate of titration was 18.3% CI95% [11.5-27.7]. 50 cases (titrated patients) and 154 controls (non-titrated) were compared: The factors significantly associated with MNT were: personal route of admission (OR = 4.6, p <0.001), discharge home (OR = 8.5 <0.001), physician low grade (OR = 2.0 p = 0.03), and initial low VAS (OR = 1.7, p <0.001). Discussion and conclusion: Physicians demonstrated poor adherence to a ubiquitous MT protocol based on initial nurse VAS or NRS evaluation, even outside care environment considerations (6.1% to 18%). They used other cognitive paths to decide MT prescription: intuitive pain assessment, paracetamol therapeutic tests, first evaluation of etiological treatment. The relevance of systematic MT is particularly challenged by young physicians, and when patients are in ambulatory care pathways. MT is safe and effective for the relief of severe pain in the ED but a single VAS evaluation at admission is not favored by physicians as the main trigger for current decisions of MT.

2019/116/OB

Introduction

In the Emergency Department at Bedford Hospital methoxyflurane, a halogenated ether aneasthetic agent, has been used as an alternative to procedural sedation since December 2017. This study aimed to evaluate a number of factors relating to its scope of use, efficacy, adverse events and discharge time post procedure.

Method

A convenience sample of patients who received methoxyflurane for analgesia to allow a procedure had prospective data collected by the treating clinician from December 2017 to March 2019. A standard data collection sheet was used, collected and analysed by the researchers. Data collected included pain score prior to administration, at 1 minute after the administration of methoxyflurane started and at 15 minutes. Data on adverse outcomes, success or failure of procedure, administration and discharge times, and user comments was also collected.

Results

60 uses of methoxyflurane were recorded. The most common indication for use was shoulder dislocation (n=19), followed by reduction of colles fractures (n=13) and manipulation of ankle fracture/dislocations (n=10). 6 cases were deemed ‘failure of procedure’. Of these 4 were shoulder relocations, 1 ankle fracture/dislocation, 1 hip dislocation. There was 1 adverse event, with a patient feeling ‘dizzy’.

Pain score was recorded in 55 cases. The mean pain score prior to administration of pentrhox was 8, the mean pain score at 1 minute following the start of adminstration was 5 and the mean pain score at 15 minutes following the start of administration was 2.

Mean time to discharge from adminstration in those cases not requiring admission (n=15), or a second procedure (n=6) was 53 minutes.

Conclusions and Discussion

Although this is a small data set from a single centre, we feel that methoxyflurane has proven itself an effective form of pain relief, allowing for a wide range of procedures to be carried out without the need for  procedural sedation.

The failure rate seems acceptable at approximately 10% whilst it appears to be generally well tolerated by patients, with only 1 minor adverse event in our data set. Discharge post procedue is prompt and the average is below the minimum 1 hour timeframe recommended for procedural sedation

Not a registered trial, no funding received.

Objectives: The misuse of prescription opioids has evolved into a national emergency in the United States (U.S.). According to the 2017 National Survey on Drug Use and Health, approximately 2 million individuals misused prescription pain relievers for the first time within the past year. According to the Monitoring the Future Survey, among youth ages 12 to 17, 4.9 percent reported past-year nonmedical use of prescription medications. Prescription opioid misuse among teenagers occurs as this population believes that they are safer than illegal substances as they are prescribed by a healthcare professional. This study examines the trends in intentional opioid exposures among teenagers reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all intentional opioid exposures in patients between 13 and 19 years from 2012 to 2018. We descriptively assessed demographic and clinical characteristics. Calls from acute care hospitals and emergency departments (ACH) were studied. Poisson regression models were used to evaluate the trends in the trends in teen intentional opioid exposures. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: Among 651,882 teen exposures reported to the U.S. PCs during the study period, 39,398 (6%) involved opioids. While the overall teenage exposure calls increased, opioid-related calls decreased (6,211 to 4,487). Among the teen opioid exposures, 72.9% were directly reported by ACH. Cases were predominantly females (62.3%). The residence was the most common site of exposure (91.4%). Multi-substance exposures accounted for 56.2% cases, with the prevalence increasing during the study period (53.9% to 58.7%). Most intentional teenage exposures were attributed to suspected suicides (65.7%) with one-fifth cases reporting abuse. Major clinical effects were seen in 5.3% teen opioid exposures and there were 174 deaths. Among cases, 18.1% were admitted to a critical care unit (CCU) while 22.3% were admitted to a psychiatric facility. The proportion of cases from ACH increased during the study period (65.9% vs 78.6%). Hydrocodone (36.1%) was the most common opioid reported in intentional teen opioid cases followed by tramadol (19.2%). Benzodiazepines were the most common non-opioid co-occurring substance reported for cases (13.5%). The most frequent clinical effect demonstrated was drowsiness (40%), while tachycardia (21.9%) and vomiting (15.7%) were commonly seen. Naloxone was used in 15.7% of cases. In approximately 40% of the cases, these therapies were used after recommendations from the PCs. Intentional teenage exposures decreased by 27.8% (95% CI: -30.5, -25.7%, p<0.001) during the study period.

Conclusions: The current study used data from a national real-time poison system and demonstrated that the teenage opioid exposures due to intentional reasons decreased during the study period. These trends parallel the stabilizing opioid prescribing rates as well as several state and federal public health prevention efforts.  Suspected suicides were the predominant reason for such exposures. The proportion of exposures from acute care hospitals and hospital-based EDs increased. Greater educations efforts, recovery support and behavioral approaches are key in tackling this issue in the teen population.

n/a

Background: Oligo-analgesia is common in the emergency department (ED). Methoxyflurane (Penthrox^®), a non-opioid, self-administered, analgesic is approved in Europe for the emergency relief of moderate to severe pain in trauma patients. This study aimed at demonstrating the superior efficacy of Methoxyflurane (Penthrox^®) + standard of care (SoC) analgesia (multimodal analgesia) over placebo + SoC for the management, at emergency department (ED) admittance, of moderate to severe pain secondary to trauma.

Methods: A randomised, double-blind, multicentre, placebo-controlled trial conducted at eight EDs in France between May and December 2018. Eligible patients were alert subjects (≥18 years) admitted to ED for pain secondary to trauma [pain score ≥4 on the 11-point numerical rate scale (NRS) at admission]. Patients were randomised to receive either one or 2 inhalers containing each 3 mL of methoxyflurane or 5 mL of matched placebo in association with SoC. Randomization was stratified by gender, centre and pain score at baseline (moderate pain: NRS 4-5; severe pain: NRS 6-10). The primary endpoint was the time until pain relief (PR) defined by the duration between the start of the study treatment (T0) and pain relief (≤ 30 on the visual analogic scale (VAS). VAS was assessed electronically on tablets devices at least at 5, 10, 15, 20, 30, 60, 90 and 120 min.

Results: 359 patients were randomised and 351 were analysed for efficacy (178 Penthrox^®; 173 placebo). Baseline characteristics were comparable between groups with a median VAS at T0 of 66 mm and 263/351 (75%) patients with severe pain. Main trauma localisations were upper limb (43%) or lower limb (35%) and main type of injury were contusion (34%), fracture (20%), sprain (19%), or wound (17%). Median time to PR was 35 min (95% CI: 28 to 62) in the Methoxyflurane-SoC group and not reached (NR) in the SoC-placebo group (92 to NR) [HR=1.93 (1.43; 2.60), p <.001]. Efficacy increased in the severe pain subgroup with a hazard-ratio (HR) at 2.52 (1.71: 3.72). The proportion of responders (VAS decrease > 30%) at 60 mn was 76% (n=135/178) in the Methoxyflurane -SoC vs. 55% (n=94/172) in the SoC-placebo group, p<0.01. 67/178 (37.6%) in the Methoxyflurane-SoC group and 47/173 (27.2%) in the SoC-placebo group did not received any SoC analgesia. 6/178 (3.4%) in the Methoxyflurane -SoC group and 9/173 (5.2%) in the SoC-placebo group received strong opioids. Two severe adverse events (AEs) occurred in the Methoxyflurane-SoC group including one that was assessed as related to treatment and most AEs (diziness, feeling drunk, somnolence) were of mild (111/147) or moderate intensity (34/147).

Discussion & conclusions: This double-blind controlled trial demonstrated that Penthrox^® in multimodal analgesia is superior to SoC-placebo in achieving pain relief for trauma patients. The results confirm the rapid onset of action of Penthrox^®. Treatment efficacy increased in patients with severe pain.

 

Trial Registration: This study has been registered under EUDRACT N°: 2017-004469-28 Funding: This study was funded by MundiPharma SAS (the sponsor of the study)

Aim:

To describe the indications, used medication and safety of procedural sedation in a Belgian University Hospital Emergency Department.

 

Methodes:

We performed a prospective observational cohort study of all patients who underwent procedural sedation and analgesia in a Belgian Emergency Department between April 2017 and April 2018. Standardised forms were used to collect data on patient demographics, indication, performed procedures, used medication and the occurence of adverse events classified by the SIVA adverse event reporting tool.

 

Results:

171 patients were included in the study. Median age was 53 years, 56% were male. 40% of patients were ASA class 1, 37% were ASA class 2 and 22% were class 3 or higher. The majority of the patients underwent procedural sedation for cardioversion (34%), reduction of fractures (30%) or dislocations (26%). Propofol and ketamine were the most frequently used medications. Adverse events occured in 12% of cases, mostly due to apnoea (33%), hypoxia (19%) and emesis (19%). All of the adverse events were transient. None of the patients suffered an adverse outcome.
Logistic regression analysis revealed ASA class 3 or higher as independent risk factor for adverse events.

 

Conclusion:

This Belgian cohort study supports the results of international studies showing that procedural sedation in the emergency department is safe, with a 12% adverse event rate and without occurence of adverse outcomes.

no funding

Background:

Torus or buckle fractures of the distal radius are the most common forearm fractures in children. Because of their inherent stability and few complications, recent guidelines have recommended treatment with non-rigid removable immobilisation devices instead of rigid cast immobilisation. Routine follow-up consultation and radiographic exams are also questioned and deemed unnecessary. This newer approach may have multiple advantages, such as patient and parent convenience, improved wrist functionality and overall cost reduction. The main purpose of this study was to audit a university hospital approach to children with torus fractures of the distal radius, to assess whether recommendations are followed.

Methods:

This study was a retrospective cohort study and evaluated children under 18 years old who presented with a suspected fracture of the wrist or the distal forearm to the emergency department (ED) of the Ghent University Hospital in 2016 and 2017. A subgroup analysis was done for children treated for torus fracture of the distal radius. Diagnosis, treatment and follow-up were evaluated. Proportions of children treated with a non-rigid removable immobilisation device and median numbers of follow-up consultations and x-rays were examined. To explore diagnostic difficulties, inter-observer variability between 2 experienced investigators who reviewed all radiographic images was assessed using kappa statistics. Finally, comparison was done with findings from the literature.

Results:

In total, 205 children with a suspected distal forearm fracture were included. Thirty-nine of them were treated as a torus fracture at the ED, regardless of the correctness of the diagnosis. Diagnosing torus fractures by physicians at the ED had sensitivity, specificity, positive and negative predictive values of 55%, 90%, 56% and 89% respectively. Inter-observer variability assessment between the 2 reviewers showed a Cohen’s kappa score of 0.64 (95% CI of 0.38-0.55), meaning a rather poor or moderate agreement, depending on the guideline. All patients with a suspected torus fracture of the distal radius were treated with a rigid non-removable plaster backslab. Most of them had at least 2 routine follow-up consultations and 1 radiographic exam. Besides prolonged discomfort in 3 patients, no serious fracture-related complications occurred in the torus fracture group. Four patients (10%) however had a material related complication.

Discussion & Conclusions:

This audit of a university hospital approach to paediatric torus fractures of the distal radius showed a conservative approach without the use of non-rigid removable immobilisation devices and with several routine follow-up consultations and x-rays. These findings were also found by other institutions, that described several barriers towards an implementation of recently published recommendations and guidelines. Similarly to other studies that mentioned a significant rate of missed and misdiagnosed torus fractures, this study found diagnostic difficulties. To summarise, recent guidelines for the treatment of torus fractures of the distal radius are not followed. These findings may stimulate intra-hospital multidisciplinary discussion to improve diagnostic accuracy and patient management. They may also guide further research, in which focus may be switched from torus fractures towards all stable forearm when assessing diagnostic and therapeutic possibilities, which may be more feasible given the diagnostic difficulties.

Trial registration: Not applicable, retrospective audit study. Funding: No external funding was provided.

Can we combine clinical decision rules to reduce imaging of the cervical spine in trauma?
A prospective pilot study.

E.J. van Leest, MD, Resident Emergency Physician, D.S.E Varin, MD Emergency Physician, A.V. Brown, MD, Emergency Physician, E.Birnie, PhD, Statistician. Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.  Designated speaker: E.J. van Leest.

Abstract
Introduction The National Emergency X-Radiography Utilization Study low risk (NEXUS) criteria and the Canadian C-spine (CCS) rule are validated  rules with high specificity and negative predictive values to evaluate the need for radiography. Dr. Scott Weingart proposed/suggested a combined NEXUS-CCS rule as optimal. Aim of our study is to investigate whether the diagnostic characteristics of the combined NEXUS-CCS rule  is comparable or better  than the separate/single NEXUS and CCS rules.
Methods This is a prospective pilot study (n=99) of adult patients with suspicion of cervical spine injury by using NEXUS criteria, presenting at the Emergency Department (ED). The NEXUS, CCS and NEXUS-CCS rule were scored before Computed Tomography (CT). CT outcome and treatment were noted. The CT amounts, negative predictive values and NRI were estimated.
Results  The incidence of cervical fracture was 3.0%. Two of the three patients had multiple fractures with a sum of 6 fractures. Dens fracture (n=1), anterior/posterior arch of C1 (n=2), fracture of calcificated anterior corpus ligament (n=2), fracture of anterior syndesmophyte (n=1). The amount of C spine CT’s was 64.6% [95% CI: 54.4-74.0] compared with 88.9% [95% CI: 81.0-94.3] with NEXUS and 62.6% [95% CI: 52.3-72.2] with CCS. Negative predictive value was 11.5% [95% CI: 5.9-19.6] for NEXUS, 37.5% [95% CI: 27.8-48.0] for CCS and 35.4% [95% CI 25.9-45.8] for NEXUS-CCS. An instable fracture was missed by NEXUS-CCS and the CCS rule alone due to a young frail M. Bechterew patient.
Conclusion Our small size pilot study suggests that the test characteristics of the combined NEXUS-CCS rule are comparable to the CCS rule alone and suboptimal compared to the NEXUS rule. The combined NEXUS-CCS rule cannot accurately diagnose, nor rule out, cervical spine injury. A refinement by adding an extra criteria to select patients with bone or muscle disease as high risk patients needs further investigation.

Keywords
Clinical decision rule, cervical spine injury, cervical spine fracture, trauma patients, imaging, cervical spine Computed Tomography (CT), NEXUS, Canadian C Spine rule.

 

 

 

 

Background

Patients taking direct oral anticoagulants (DOACs) commonly undergo computed tomography (CT) head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK NICE head injury guideline group.

Methods

An observational cohort study was performed in 2 UK major trauma centres (Sheffield, Hull) between 26^th June and 3^rd September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and emergency department information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery; ICH; or death due to head injury. Adverse outcome risk was calculated overall; and for GCS 15 patients who did not meet NICE criteria for CT head imaging.

Results

169 patients with minor head injury were included (69% GCS 15, 31% GCS 14). Patients were elderly (median 82 years) and most frequently injured from ground level falls (96%). Overall risk of adverse outcome was 4% (7/169, 95%CI 2-8%). 7 patients had ICH, of whom 3 died. No patient received critical care management or underwent neurosurgical intervention. Risk of adverse outcome in patients who did not meet NICE imaging criteria was 2% (2/96, 95%CI 0-8%). Of these NICE false negative cases, one patient presented with GCS 15 and a headache; the other was GCS 15, asymptomatic, but fell >2m.

Conclusions

The risk of adverse outcome was low, particularly in patients not meeting NICE CT criteria. No patient with ICH underwent neurosurgery or received critical care, suggesting that imaging did not influence management. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury whilst taking DOACs.

Introduction: Colles’ type distal radial (wrist) fractures are one of the commonest fractures seen in the Emergency Department (ED). Fracture displacement is usually associated with a fall onto an outstretched hand, especially in the elderly. These displaced fractures typically undergo manipulation under anaesthesia (MUA) in ED, undertaken ‘blindly’ without real time imaging. Inadequate fracture reduction or subsequent re-displacement of these injuries frequently results in surgical fracture fixation (closed MUA failure) and occurred in up to 30% of cases in small local audit. 

Use of ultrasound to guide distal radial fracture reduction as precisely as possible might reduce instability and subsequent need for surgery. We have therefore commenced a Royal College of Emergency Medicine (RCEM) funded project ('Ultrasound Directed Reduction of Colles' Type distal radial fractures - UDiReCT') to determine whether a large trial to assess the benefit and cost effectiveness of ultrasound guided fracture reduction is both justified and feasible. 

Methods: Firstly we have conducted a trainee led service evaluation of Colles’ type fracture ED management to estimate the ED MUA failure rate (surgery with 6 weeks of ED MUA) rate and current use of ultrasound, across 16 UK EDs over a two month period from February 2019. Only anonymous data was used and this evaluation was exempted from formal ethical approval after review by the sponsoring institution. All adult distal radial fractures were identified from radiology and ED databases over a two week case identification period and screened against defined eligibility criteria. We excluded those under 18yrs, patients with volar displaced (Smith's) fractures and those followed up elsewhere. All fractures undergoing ED MUA were followed up for 6 weeks to determine the subsequent need for surgery. This service evaluation is being followed by a single blind feasibility RCT, comparing ultrasound guided fracture reductions with standard care, in two models of care. Together with the service evaluation, this trial will determine the potential participant recruitment rate, test a definitive trial protocol and check data collection for a future full multicentre trial.

Results: 328 distal radial fractures were identified over the two week case identification period. Of these 89 patients underwent ED MUA with a subsequent need for surgery identified in 34 (39.5%) of 86 with follow up data. No sites routinely used ultrasound to guide reductions. Our conference presentation will outline findings from the service evaluation, speculate on why ultrasound might be beneficial and discuss the controversies and challenges in this field of research. We will then describe in detail the forthcoming UDiReCT RCT protocol and discuss opportunity for European collaboration.

Our trial is funded by the Royal College of Emergency Medicine and registered with ClinicalTrials.gov NCT03868696

Background

Undertreatment of acute pain in the emergency setting remains a widespread problem, and elderly patients receive even worse pain treatments than others. The probability that these patients receive analgesic treatment is up to 20% lower than that of younger patients.

Low-dose methoxyflurane is an inhaled, rapid-acting, non-narcotic analgesic now approved in Europe that may overcome some barriers to effective pain management. There is, however, a lack of data from large, randomised, active-controlled trials.

Methods

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a Phase IIIb, open-label, randomised controlled trial conducted by the Pain Group of the Spanish Society of Emergency Medicine/Spanish Clinical Research Network in 14 Spanish emergency units from July 2017 to April 2018. We present a post hoc analysis in the subgroup of patients aged ≥65 years. At triage, adults with acute moderate-to-severe trauma pain (score ≥4 on the 11-point Numeric Rating Scale [NRS]) secondary to trauma were randomised 1:1 to receive inhaled methoxyflurane (up to 2´3mL vials) or SAT (standard analgesic treatment per each site’s own analgesic protocol) while in the unit. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Efficacy endpoints included change in NRS pain intensity (primary endpoint), and time to onset of pain relief (co-primary endpoint) for 20 min after start of treatment, and patient/clinician-reported outcomes, which were analysed in an exploratory manner for the elderly subgroup using 2-tailed t-tests.

 

Results

The elderly subgroup included 33 methoxyflurane-treated patients and 26 SAT-treated patients, (19.34% of the patients included in the whole trial) 30.5% males, mean±SD age 73.6±6,0 years with mostly fractures and/or contusions. 22 of 26 (85%) patients in the SAT group received non-steroidal anti-inflammatory drugs (mainly intravenously) and 4 received opioid analgesics. Mean (±SD) baseline NRS pain intensity was 8.10±1.62 in the methoxyflurane group and 7.28±1.97 in the SAT group. Mean decreases from baseline in NRS pain intensity at 3, 5, 10, 15 and 20 were 1.61, 2.37, 3.43, 4.04 and 4.78 for methoxyflurane and 0.60, 1.00, 1.81, 2.53 and 3.19 for SAT. The treatment difference was statistically significant in favour of methoxyflurane at all time points. Time to first pain relief was significantly shorter for methoxyflurane than SAT (5.55 vs. 12.38 min; difference: -6.43min; 95%CI: -10.27, -2.58, p<0.001), as was time to first meaningful pain relief (12.57 vs. 25.07 min; difference: -12.10min; 95%CI: -18.06, -6.14; p<0.001). Both treatments scored highly for patient and clinician satisfaction with the efficacy, comfort and safety of treatment (from 7.64±2.35 to 8,71±1.87). Clinicians rated methoxyflurane significantly better for comfort; difference 1,17 95%CI 0.52, 1.83; p<0,001. Methoxyflurane exceeded patient/clinician expectations of treatment in 70%/64% of cases versus 50%/31% for SAT. Adverse events were reported for 8 methoxyflurane-treated patients (dizziness -2-, drowsiness -2-, euphoria, oral itching, pain and sickness) and 3 SAT-treated patients (hospitalisation, nauseas and pain)

 

Conclusions

These results support consideration of methoxyflurane as a non-narcotic, easy-to-use, rapid-acting, first-line alternative to currently available analgesic treatments for elderly patients with trauma pain.

 

EudraCT: 2017-000338-70; NCT03256903 / Study funded by Mundipharma Pharmaceuticals S.L.

Background

The use of opioids for treating pain in the emergency settings is a pillar of current options, however some health professionals are reluctant to prescribe opioids, which contributes to the problem of poor pain management. Therefore, there is an unmet need for a non-narcotic, rapid-acting, safe and effective analgesic. Inhaled methoxyflurane has recently been approved in Europe for the emergency relief of moderate-to-severe pain in conscious adults with trauma and associated pain. The InMEDIATE trial compared the pain relief achieved with methoxyflurane versus standard analgesic treatment (SAT), comprising any opioid or non-opioid analgesia by any route as defined per the pre-registered local analgesic protocol used in each site. The results of the trial shown that although patients included suffered a severe mean baseline pain, more than three quarters of the group (77.85%) were treated with intravenous non-opioids. Results of a post hoc subgroup analysis of methoxyflurane vs. intravenous non-opioid analgesia (IV-NOP) are reported here.

 

Methods

 

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a phase IIIb, open-label, randomised controlled trial conducted in 14 Spanish emergency units from July/2017 to April/2018. At triage, adults with acute trauma pain, NRS_0-10 score ≥4, secondary to trauma were randomized 1:1 to receive inhaled methoxyflurane or SAT. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Efficacy endpoints included change in pain intensity (primary endpoint), and time to onset of pain relief (co-primary endpoint) for 20 min after start of treatment, and patient/clinician-reported outcomes. The treatments were compared in an exploratory manner using 2-tailed t-tests.

 

Results

156 patients received methoxyflurane and 104 IV-NOP, mean age 45.3±18.7 vs 45.5±18.2 years; 51% vs 43% male, and mean baseline pain scores 7.63±1.39 vs 7.48±1.55, respectively. In the IV-NOP group almost all patients (92,3%) received non-steroidal anti-inflammatory drugs [NSAIDs], ± other non-opioids ± diazepam). Other drugs were metamizole and paracetamol. Mean pain relief was significantly greater (p<0.001) for methoxyflurane than IV-NOP at all-time points, with the largest treatment difference at 10min (1.81; 95% CI: 1.31, 2.31). Mean changes from baseline to 3, 5, 10, 15 and 20min were 1.80, 2.73, 3.66, 4.20 and 4.73 for methoxyflurane and 0.56, 1.11, 1.84, 2.58 and 3.30 for IV-NOP. Time to onset of pain relief was significantly shorter for methoxyflurane than IV-NOP (mean 5.52 vs. 12.19min; difference: -6.26min; 95% CI: -8.28, -4.25min; p<0.001) as was time to first meaningful pain relief (mean 12.39 vs. 24.37min; difference: -11.58min; 95% CI: -15.22, -8.33min; p<0.001). Investigators and clinicians scored significantly better effectiveness and comfort with methoxyflurane vs IV-NOP (p<0,001) using a NRS_0-10 scale. Methoxyflurane exceeded patient/clinician expectations of treatment in 75%/71% of cases vs. 40%/21% for IV-NOP. 24% methoxyflurane-treated patients and 4% of IV-NOP patients experienced adverse events. The most frequent event was dizziness (13,4%), mainly mild and transient.

 

Conclusions

Methoxyflurane provided superior pain relief to IV non-opioid analgesics in patients with acute trauma pain, with higher patient and clinician satisfaction with methoxyflurane treatment.

EudraCT: 2017-000338-70; NCT03256903 /Study funded by Mundipharma Pharmaceuticals S.L.

Background: Direct Oral Anticoagulants (DOACs) are one of the novel treatments in clinical practice in decades. These drugs been proved to have analogue efficacy in thromboembolic prevention compared to Vitamin K Antagonist (VKAs) and have set doses with no requirement of require regular international normalisation ratio blood test monitoring. Those characteristics contributed to a rapid spread of DOACs in clinical practice. considering them a valid alternative to VKAs in patients requiring anticoagulation

Objective: to evaluate the differences in the risk of developing early, delayed as well global bleeding after a minor head injury among patients treated with DOACs compared to those treated with VKAs.

Methods: We performed a retrospective observational study on patient admitted to our Emergency Department from Jun 1^st, 2017 to Aug 31^st, 2018 due to a MTBI. All patients with a GCS score of 13-15, regardless of the presence of loss of consciousness (LOC) or amnesia immediately after the injury, were included in the study. All patients in AOT accessing to the ED receive an immediate CT brain scan (T0) and a second CT scan after 24 hours (T1) with a clinical observation period between the two exams before discharge from the ED. All the patients were then followed for the next 30 days for late ICH (T2) after discharge.

Results: during study period we enrolled 451 patients, 268 VKAs versus 183 DOACs. We did not observe significant differences in basal characteristics between the two groups of patients (DOACs vs. VKAs). 7.7% (14/183) of patients in DOACs presented an overall intracranial bleeding against 14.9 (40/268) of those receiving VKAs (p=0.026), while immediate bleeding was present in 5.5% (10/183) of patients in DOACs against 11.6% (31/268) of AVK patients (p=0.030). No difference was found in delayed bleeding (3.8 versus 2.3, p=0.570). No difference was showed between DOACs and AVK groups in neurosurgical treatment. Finally, none of the patients discharged at home after with negative CT scan after 24 hours ED observation presented ICH during the following 30 days.

The univariate analysis showed to be factors associated with a risk of global intracranial bleeding: AVK treatment, a high impact trauma, post-traumatic amnesi, loss of consciousness, a GCS lower than 15, presence of cranial fracture and a trauma beyond the clavicles. When subsequent multivariate analysis was performed, the risk factors confirmed as independent predictors of risk for a global intracranial haemorrhage in patients with an anticoagulant therapy were: AVK therapy (OR 2.327, p=0.024), high energy trauma (OR 11.229, p<0.001), amnesia (OR 2.814, p=0.017), loss of consciousness (OR 5.286, p=0.037), a GCS lower than 15 (OR 4.719, p=0.001) and the presence of an objectively lesion above the clavicles (OR 2.742, p=0.008).

Conclusion: patients treated with DOACs seem to present a lower risk of post-traumatic bleeding compared to patients treated with AVKs. Delayed bleeding, although not negligible, does not appear to aggravate the outcome of patients.

Objectives: Suicides are a global phenomenon, with the World Health Organization estimating the annual mortality rate due to suicides to be 10.7 per 100,000 individuals. In Europe, self-harm attempts in 2015 exceeded 50,000. According to the Centers for Disease Control and Prevention, the rates of opioid-related suicides and unintentional overdoses doubled between 2000 and 2017 in the United States (U.S.). This study aims to characterize the opioid-related suspected suicide attempts (SSAs) that are reported to the U.S. National Poison Data System (NPDS).

Methods: The NPDS was queried for opioid-related SSAs that were reported to the U.S. poison centers (PCs) from 2011 to 2017. We identified and descriptively assessed the relevant characteristics of SSAs. Calls from acute care hospitals and emergency departments (collectively, hospitals) were studied. Poisson regression models were used to evaluate the trends in the number and rates (per 100,000 human exposures) of SSAs. Percent changes from the first year of the study (2011) were reported with the corresponding 95% confidence intervals (95% CI).

Results: Overall there were 184,645 opioid-related SSA cases reported to the U.S. PCs during the study period. Among these, 84% were directly reported by hospitals. Cases between 20 and 39 years (39.3%) constituted the most common age group. The proportion of older adults above 60 years of age almost doubled during the study period (7.4% to 14.2%). Females accounted for 63.8% of cases. Most exposures occurred in a residence (94.2%). More than one substance was reported for most cases (78.2%). Major clinical effects were demonstrated in 9.4% of exposures and the case fatality rate was 0.8%. Major effects were less common in teenagers (4.3%) and there were 92 deaths in this age group during the study period. Among cases, 33.2% were admitted to a critical care unit while 22.6% were admitted to a psychiatric facility directly from the emergency department. The proportion of cases from hospitals increased during the study period (80.4% to 86.4%). Hydrocodone (36.7%) was the most common opioid reported in SSA cases followed by tramadol (20.8%). Benzodiazepines were the most common non-opioid co-occurring substance reported for SSAs (28.9%). The most frequent clinical effect demonstrated was drowsiness (51.8%), while tachycardia (22.5%) and respiratory depression (10.3%) were commonly seen. Naloxone was used in 28.3% cases. In approximately one-fourth of the cases, naloxone was used after consultation and recommendation from the PCs. SSAs decreased by 24.4% (95% CI: -25.7, -23.1%, p<0.001) while the SSA rate also decreased by 16.5% (95% CI: -23.4%, -9.3%, p<0.001).

Conclusions: SSA cases handled by the PCs decreased significantly, however there was a rise in the older population. There was a low fatality rate.  The majority of calls originated from the hospitals or emergency department.  Hydrocodone and tramadol were the most common opioids reported for the sample. Personalized evidence-based strategies, population-level interventions, creation of protective environments, and better screening of patients at risk of suicide are some key measures to limit suicide attempts. PCs play a significant role in the care of this patient population and partner closely with emergency personnel.  

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Introduction: Major injury is a time-dependent pathology in which the quantification of vital prognosis is fundamental for professionals. The objective of this study is to evaluate the ability of the Shock Index (SI), Modified Shock Index (MSI) and Age Shock Index (aSI) to predict early mortality (2 days) from the index event.

Material and methods: Prospective longitudinal longitudinal study, between April 1, 2018 and April 30, 2019. The study was developed on a reference population of 1,021,086 inhabitants, distributed in four provinces of Spain (Burgos, Salamanca, Segovia and Valladolid). All the hospitals included in the study have ICU and ample surgical capacity. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support Units and transferred to the emergency services with major injury diagnosis, and did not meet any exclusion criteria: minors, cardiorespiratory arrest, death and pregnant women.

Demographic data (age and gender) and clinical parameters (systolic, diastolic, mean and heart rate) for the calculation of SI, MSI and aSI were collected during the first contact with the patient in prehospital care with the LifePAK® 15 monitor (Physio-Control, Inc., Redmond, USA).

The need for admission, the Intensive Care Unit and the mortality data were obtained by reviewing the patient's electronic history after 3 days.

The main dependent variable was mortality from any cause in the hospital before the first two days from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) was calculated for each scale in terms of 2-day mortality, as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 220 patients were included in our study. The median age was 62 years (IQR: 38-68 years), 35.9% of them were women. The 2-day mortality was 5.1% (11 cases). 18.6% (41 cases) of patients required ICU.

The AUROC obtained were SI (0.569, 95% CI: 0.38-0.75, p = 0.452), MSI (0.625, 95% CI: 0.44-080, p = 0.174) and aSI (0.775, 95% CI: 0.61-0.94; p = 0.019). The value with the best overall sensitivity and specificity for the aSI was 37.05, sensitivity of 90.9% (62.3-98.4), specificity of 67.0% (60.4-73.0), positive predictive value 12.7 (7.0-21.8), negative predictive value 99.3 (96.1-99.9), Likelihood ratio (+) 2.75 (2.10-3.60), Likelihood ratio (-) 0.14 (0.02-0.89) and odds ratio 20.29 (2.55-161.73).

Conclusions: The prehospital aSI has an excellent capacity to predict the early mortality of patients with major injury, and is a diagnostic tool, cheap, easy to obtain and reliable that can help in the clinical decision making, as well as in the selection of the center Hospital more suitable, with intensive care unit and surgical capacity.

The study was approved by the Research Ethics Committee of all participating centers (reference CEIC: #PI 18-010, #PI 18-895, #PI 2018-10/119, #PI MBCA/dgc and #CEIC 2049). All patients (or guardians) signed informed consent, including consent for data sharing. This research has received support from the Gerencia Regional de Salud (SACYL) for research projects in Biomedicine, Healthcare Management and Healthcare Care, with registration number GRS 1678/A/18, principal investigator: Francisco Martín-Rodríguez, as part of the "Use of early warning scales in the prehospital scope as a diagnostic and prognostic tool", and Scholarship for the intensification of the research activity for the year 2019, with registration number INT/E/02/19 from the Gerencia Regional de Salud (SACYL.

Background: There were more than 72,000 overdose-related deaths in the United States in 2017, with 68% of these fatalities involved opioids. Tramadol prescriptions increased by 88% between 2008 and 2013. Tramadol-related emergency department visits involving misuse or abuse of tramadol increasing by 250% between 2005 and 2011. This study aims to examine the national trends in tramadol exposures reported to U.S. poison centers (PCs).

Methods: The National Poison Data System (NPDS) was queried for all closed, human exposures to tramadol from 2012 to 2018 using the American Association of Poison Control Center (AAPCC) generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Tramadol reports from acute care hospitals and EDs were analyzed as a sub-group. Trends in tramadol frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 84,800 tramadol exposures reported to the PCs from 2012 to 2018, with the calls decreasing from 13,113 to 9,599 during the study period. Among the overall tramadol calls, the proportion of calls from acute care hospitals and EDs increased from 53.5% to 60.9% from 2012 to 2018. Multiple substance exposures accounted for 52.1% of the overall tramadol calls and 62.4% of the calls from acute care hospitals and EDs. The most frequent co-occurring substances reported were benzodiazepines (13.9%) and alcohol (8.9%). The residence was the most common site of exposure (95.7%) and 64.4% cases were enroute to the hospital when the PC was notified. Tachycardia and hypertension were the most frequently demonstrated clinical effects. Naloxone was a reported therapy for 7.9% cases, with this therapy being performed prior to PC contact in most cases. Demographically, 61.2% of cases were females, and the most frequent age groups were 20-39 years (33.1%) and 40-59 years (25.8%). Suspected suicides (45.3%) and intentional misuse (7.8%) were commonly observed reasons for exposure, with the proportion of suicides being higher in cases reported by acute care hospitals and EDs (66.2%). Approximately 18% of the patients reporting tramadol exposures were admitted to the critical care unit (CCU), with 11% of patients being admitted to non-CCU. Major effects were seen in 5.1% cases and the case fatality rate for tramadol was 0.5%, with 416 deaths reported. There were 208 deaths reported within acute care hospitals and EDs during the study period. The frequency of tramadol exposures decreased by 26.8% (95% CI: -28.8%, -24.8%; p<0.001), and the rate of tramadol exposures decreased by 20.7% (95% CI: -29.9%, -1.4%; p=0.002).

Conclusions: PC data demonstrated a decreasing trend of tramadol exposures, which may in part be attributed to the rescheduling of this medication by the Drug Enforcement Administration to Schedule IV in 2014. Our study demonstrated a significant proportion of tramadol exposures associated with suicide. Despite an overall decreasing trend in tramadol exposures, there was an increase in tramadol exposure reports from acute care hospitals and EDs during the same time period.

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Aim: The medicalization policy of the French armed forces places military general practitioners (MGP) near the front line, allowing soldiers to carry out their actions away from their base camp, while maintaining operational capacities. Thus, the activity is split between primary care and combat casualty care. Regional anaesthesia (RA) techniques could be useful in both cases. The aim was to assess the state of art of RA use among MGP and to track the limiting factors.

 

Procedure: we conducted a multicentric observational study, with MGP from metropolitan France that realized at least one mission during the last 3 years. Each one completed a questionnaire about experience, education and RA practice during the last mission. We used chi-square tests or Fisher exact test in case of insufficient number, to cross RA practice with demographic features, experience markers and mission’s characteristics. The threshold for significance was a p-value < 0.05.

 

Results: From October 2015 to December 2016, we collected 138 answers, of which 114 (83%) were included and analysed. Mean age was 33 ± 5, consistent with deployed MGP profile. RA scholar education concerned 42/114 (37%) MGP, whereas RA practice based on companionship concerned 94/114 (82%) of them. During their last mission, 26/114 (23%) MGP had performed at least one RA technique. The guidance technique was anatomical for 68/70 (97%) of procedures. Among all responders, 25/114 (22%) didn’t perform a RA technique even though they thought it was indicated. Their main reasons were lack of techniques’ mastery (38%), missing equipment (20%), time shortness (15%), and hygiene issues (12%). None of the tested factors were statistically associated with RA practice. Although senior MGPs tend to practice (p = 0.06) RA more, which seems to be consistent with previous data.

 

Conclusion: Environmental factors, patients recruitment and lack of techniques’ mastery seemed to be the main explanations of such a low practice rate. Development of RA techniques in a military environment should be associated with an adapted training that takes tactical background into consideration. It has to focus on what is feasible for primary care on one hand and combat casualty care on the other hand. Since it has been largely widespread on operations fields, and validated for RA techniques guidance in civilian practice, ultrasonography should be considered as a valuable aid in some cases. Even though RA education program has well been written for anaesthesiologists, a training program for MGPs for RA should be different and perhaps mainly based on clinical practice.

Introduction: The time-dependent diseases represent one of the most frequent causes of attention by the Prehospital Emergency Medical Services (PhEMS), one of the most frequent reasons for hospital admission and one of the main potential causes of early mortality.The main objective was to evaluate the ability of the prehospital National Early Warning Score 2 (pNEWS2) to predict early mortality (before 48 hours) from the index event.

Material and methods: Multicentric prospective observational longitudinal study of cohorts, between April 1, 2018 and March 30, 2019. The study was developed on a reference population of 1,113,073 inhabitants, distributed in four provinces of Spain (Burgos, Salamanca, Segovia and Valladolid), in a geographical area of 41,403 km2. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support and transferred to the Emergency Department, and did not meet any exclusion criteria: under 18 years old, cardiorespiratory arrest, exitus, pregnant women, patients with psychiatric pathology or terminal pathology or discharged in situ. Demographic data (age and gender), vital parameters (respiratory rate, oxygen saturation, heart rate, systolic blood pressure and body temperature), clinical observations (consciousness level and use of supplemental oxygen) were collected during the first contact with the patient in prehospital care.

The temperature was measured using the ThermoScan® PRO 6000 tympanic thermometer (Welch Allyn, Inc., Skaneateles Falls, USA), and the rest of the vital parameters with the LifePAK® 15 monitor (Physio-Control, Inc., Redmond, USA) .

Diagnosis and mortality data were obtained by reviewing the patient's electronic history at 3 days from the index event.

The main dependent variable was mortality from any cause in the hospital before the first 48 hours from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) of the pNEWS2 scale was calculated in terms of 2-day mortality as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 1466 patients were included in our study. The median age was 69 years (IQR: 54-81 years), 40.9% of them were women. The 2-day mortality was 5.6% (82 cases).

The AUCROC of pNEWS2 was 0.873 (0.82-0.92, p <0.001). The value with the best sensitivity and specificity overall was 9 points, sensitivity of 74.4% (64.0-82.6), specificity of 84.5% (82.5-86.3), positive predictive value 22.2 (17.7-27.5), negative predictive value 98.2 ( 97.3-98.8), Likelihood ratio (+) 4.81 (4.03-5.74), Likelihood ratio (-) 0.30 (0.21-0.44), odds ratio 15.88 (9.47-26.63) and diagnostic accuracy of 84.0% (82.0-85.8).

Conclusions: Being aware of the patient's physio-pathological situation is basic to managing the situation, where early diagnosis is essential.

The PhEMS should evaluate the implementation of pNEWS2 as a routine evaluation among its procedures, since it effectively serves to predict mortality from any cause and the detection of high risk patients at an early stage.

The study was approved by the Research Ethics Committee of all participating centers (reference CEIC: #PI 18-010, #PI 18-895, #PI 2018-10/119, #PI MBCA/dgc and #CEIC 2049). All patients (or guardians) signed informed consent, including consent for data sharing. This research has received support from the Gerencia Regional de Salud (SACYL) for research projects in Biomedicine, Healthcare Management and Healthcare Care, with registration number GRS 1678/A/18, principal investigator: Francisco Martín-Rodríguez, as part of the "Use of early warning scales in the prehospital scope as a diagnostic and prognostic tool", and Scholarship for the intensification of the research activity for the year 2019, with registration number INT/E/02/19 from the Gerencia Regional de Salud (SACYL.

Background: Emergency medical services (EMS) are key component of prehospital care. Evidence on EMS performance and its regional variation is limited. We sought to describe epidemiologic characteristics of ambulance transport to the emergency department (ED) and possible regional variations in Japan.

Methods: We conducted a nationwide, population-based, descriptive review of anonymized ambulance transport records in Japan. The EMS system in Japan is operated by local fire departments and is activated by phoning 119. The data were obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to the emergency medical institution by EMS from January 1 to December 31 in 2016 were enrolled in this study. We excluded patients who were not transported. We described regional variations with eight divisions; Hokkaido, Tohoku, Kanto, Chubu, Kansai, Chugoku, Shikoku, and Kyushu/Okinawa regions.

Results: Over the study period, there were 5,707,177 transported to a hospital. The median age of the patients was 69 [interquartile range (IQR) 44-82] years and 50.6% of them were male. Patients aged over 65 years were 56.4%, and those aged 75 to 84 years were the largest group (22.3%). The median time duration from EMS call to EMS arrival on scene was 8 (IQR 6-10) minutes and that from EMS arrival to medical facility was 34 (IQR 27-43) minutes. The median time durations from EMS call to EMS arrival at the scene were similar among regions, which were ranged from 7 to 9 minutes. The longest median time duration from EMS call to hospital arrival was 38 minutes (Kanto region), whereas the shortest median time duration was 31 minutes (Chubu and Kyushu/Okinawa regions).

Conclusions: We demonstrated epidemiological profile of EMS performance and regional variations in Japan. In this nation-wide, population-based study, we found a wide regional variation in time to transport patients to medical facility.

Background

Developing new prehospital quality and performance measures is important as previous outcome measures have mainly focussed on response times or on specific emergency conditions. There has been little work to identify what is important to patients and the public, or to identify measures that reflect the wide range of calls and conditions faced by the ambulance service.  The Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) research programme was commissioned with the dual aims of developing methods for linking patient level ambulance data to other health information and to develop better ways of measuring ambulance service quality and performance.  In this abstract we aim to assess the outcome and performance measures developed for the PhOEBE study against criteria for good outcome measures.  

Method

Following a substantial programme of consensus work (interviews, consensus conference, Delphi study) to select and refine a set of outcome and performance measures, we constructed six candidate measures using the PhOEBE linked dataset. We then undertook a review of published literature to identify key criteria for good indicators, and used this to assess whether the measures developed for the PhOEBE study are good indicators of the quality and performance of the emergency ambulance system. The review identified six criteria for good indicators (important to users; valid and evidenced based; use reliable data; be statistically robust; simple to understand; remediable). The assessment was undertaken by a multi-disciplinary expert group, who assessed the indicators from different perspectives, including health-care commissioners, ambulance providers and statisticians. Each of the good indicator criterion was made up of several subcomponents and each indicator was assessed against all of the subcomponents, resulting in 510 ratings by the five experts.

Results

The measures identified and developed by the PhOEBE study relate to pain; accuracy of call ID; response time (mean/median); recontacts after non-transport decisions; unnecessary ED attendances and survival from emergency conditions. The measures mostly or partly met the six criteria for good indicators. The expert panel all agreed the PhOEBE measures are important to users, and this is reflective of the involvement of patients and the public in the research process (interviews and consensus work). One of the panel felt they required more information to assess some of the measures. There were 5/510 ratings which were rated as does not meet the criteria and four of these were for the remediable component of the survival from emergency conditions measure. In addition, there is some uncertainty around the pain measure, due to the subjectivity of pain assessments.

Conclusion

Our overall findings were that the set of indicators developed for the PhOEBE study met or partly met the criteria for good indicators, and could be used to reliably measure the quality and performance of emergency ambulance service care. As a group of measures, they have relevance to different patient groups and are relevant to multiple domains of quality. The measures include both process measures and outcome measures and have been shown to be important to a wide range of stakeholders, including patients and the public.

 

Programme Grants for Applied Research (PGfAR) scheme (Grant Reference Number RP-PG-0609-10195)

AIM: This study aims to assess the effectiveness of a community based Out-of-hospital cardiac arrest (OHCA) interventional bundle in improving OHCA survival.

BACKGROUND: Out-of-hospital cardiac arrests (OHCAs) are a leading cause of death globally, and a major public health issue. Yearly, an estimated 700,000 people across Europe and North America suffer from OHCAs, of whom only approximately 10% survive. Recent data shows an increase in OHCA cases in Singapore from 800 per year (2001 – 2004) to 1500 per year (2010 – 2012). Furthermore, 70% of OHCA cases in Singapore have been found to occur in residential areas, and are associated with poorer outcomes. A core component to the interventional bundle is the Save-a-life (SAL) initiative. This initiative involves training residents of a selected geographical region in cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, along with concurrent AED installation at public-access areas of public housing blocks in these same regions. This is further supplemented by a Dispatcher-Assisted CPR (DA-CPR) program and MyResponder (mobile phone application). We hypothesized that the interventional bundle will significantly increase OHCA survival.

METHODS: This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions. Data was obtained from Singapore’s national OHCA Registry. We included all adult patients who experienced OHCA in Singapore from 2011 to 2016 within study regions, excluding EMS-witnessed cases and cases due to trauma/drowning/electrocution. Cases occurring before and after intervention were allocated as Control and Intervention groups respectively. Survival (survival to discharge/ 30-day survival post-cardiac arrest) was assessed via multivariable logistic regression.

RESULTS: 1241 patients were included for analysis (Intervention: 361; Control: 880). Intervention group had a higher mean age (70 vs 67 years), survival (3.3 % [12/361] vs. 2.2% [19/880]), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880]), bystander CPR (63.7% [230/361] vs 44.8% [394/880]) and bystander AED application (2.8% [10/361] vs 1.1% [10/880]). After adjusting for age, gender, race and significant covariates, intervention was associated with increased odds ratio (OR) for survival (OR 2.39; 95% CI: 1.02-5.62), pre-hospital ROSC (OR 1.94, 95% CI: 1.15-3.25) and bystander CPR (OR 2.29 95% CI: 1.77-2.96) compared to control group. Subgroup analysis showed that the intervention was associated with a significant increase in bystander CPR for OHCAs occurring in residential areas (OR 2.40, 95% CI 1.83 – 3.14), but not for OHCAs occurring in non-residential areas (OR 1.46, 95% CI 0.62 – 3.43).

DISCUSSION & CONCLUSION: Previous studies on improving OHCA survival have often focused solely on community CPR training programs and showed variable results. We demonstrate the effectiveness of this community based interventional bundle in improving OHCA survival. These findings support the feasibility and effectiveness of the interventional bundle, which is being scaled up as a national program, with further evaluation planned.

Non-clinical work, trial registration not applicable. Funding source: This study was supported by grants from National Medical Research Council, Clinician Scientist Awards, Singapore (NMRC/CSA/024/2010 and NMRC/CSA/0049/2013), Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012) and Duke-NUS Medical Student Research Fellowship Grant (AM-ETHOS01/FY2018/31-A31)

Background: Methoxyflurane (Penthrox) has been extensively used as an analgesic agent by Emergency Medical Service (EMS) providers in Australia since 1974. However, only in 2017 the Penthrox methoxyflurane inhaler was introduced in some European countries including Slovakia for the treatment of moderate to severe pain in adult trauma patients. Falck Zachranna, the leading EMS provider in Slovakia, included the medicine into its paramedic stuffed ambulances drug portfolio in 2018. The implementation project process consisted of some steps such as development of a checklist and a protocol for the drug administration and subsequent education and training sessions for the paramedic personnel. The aim of our study was to evaluate the efficacy and safety of methoxyflurane administered by our paramedics for one year time since the project beginning.

 

Methods: Authors used case series research design and retrospectively analyzed 127 protocols of cases where trauma patients with moderate to severe pain were treated with Penthrox. The analyzed protocols were filled by the Falck Zachranna paramedics from May 2018 till April 2019. Authors mainly focused on such parameters as subjective pain relief scores and significant side effects after the Penthrox usage, and also paramedics and patients satisfaction with the drug administration. Subjective pain relief was evaluated by the visual analogue scale (VAS), patients gave their scores before and after 10 and 20 minutes of the drug application. Side effects were considered to be significant when they severely compromised cardiovascular, respiratory or central nervous systems on the scene and required additional actions from paramedics. Paramedics and patients satisfaction levels with the drug administration (technical aspects) were measured with the 5-points Likert scale.

 

Results: During one year time our paramedics administered Penthrox to 127 patients from 18 to 92 years old (mean age approximately 52 years), predominant diagnoses were femur fractures (63% of all the cases). The mean figures for the pain scores were the following: before administration 8.07±1.133, 10 min after administration 5.94±2.10, and 20 min after administration 3.41±2.12. The median figures were 8, 5 and 3 respectively. The significance levels of both score changes (p) reached 0.01. Regarding significant side effects, only 1 case of severe bradycardia was reported (0.79% of all the cases). Totally, 91% of patients and 92% of paramedics were satisfied (or very satisfied) with the drug administration.

 

Conclusion: Authors believe that the reported figures of subjective pain relief and minimal significant side effects after the Penthrox methoxyflurane inhaler usage confirm the drug efficacy and safety when administered to adult trauma patients in the pre-hospital settings. Yet, the study needs to be extended to make the acquired statistical data more meaningful and persuasive.

Objective:

Receiving early defibrillation is one of the major factors determining outcomes of out-of-hospital cardiac arrest patients. Widely siting public access automated external defibrillators (AED) is too costly to be executable.Therefore, we need to compare and chose a more cost-effectiveness location for AED deployment. Analysis with disability adjusted life years (DALY) is a common used methods for cost-effectiveness  comparison. Objective of our study is to calculate and to compare the DALYs for out-of-hospital cardiac arrest (OHCA) patients, and the find the effectiveness of defibrillation between different types of locations.

Method:

The is a retrospective cohort study, from January 2015 to December 2016, under the help of OHCA registry of Fire Bureau of Kaohsiung City Government, using the template of Utstein resuscitation registry. DALYs is the sum of years of life lost (YLL) and years lived with disability (YLD). The YLL was calculated from the remaining standard life expectancy at the age of death. The YLD was calculated by multiplying the anticipated life duration and disability weight (DW). The DWs were assigned according to cerebral performance category (CPC) scores on the days of hospital discharge. Model of multivariate liner regression, adjusting age, sex, bystander resuscitation and defibrillation, in overall and different location types  were performed. And the effect of defibrillation on DALYs were reported and compared.

Result: 

After excluding 507 trauma-related events and 28 pediatric events (age < 18 years-old), there were 4600 non-trauma adult OHCA events in the study years. Among them, male 84.8%, mean age 69.3 +/-16.3, defibrillation rate 17.7%. The  arrest occurrence numbers and defibrillation rate, mean age and good CPC result percentage (CPC score 1 and 2) of different locations were home/residence 2480 (14.19%), 70.76 y/o (0.89%); industrial/workplace 77 (45.45%), 52.39 y/o (9.76%); sports/ recreation 39 (58.97%), 59.40 y/o (14.29%); street/highway 146 (36.99%), 60.22 y/o (5.56%); public building 31 (32.6%), 56.46 y/o (0%); assisted living/nursing home 145 (10.34%), 77.77 y/o (0%); educational institution 9 (66.67%), 52.20 y/o (42.86%); other 150 (32.67%), 61.22 y/o (1.65%), unknown/not recorded 894.

The effect of defibrillation on DALYs  in different location were: home/residence 1.06*; industrial/workplace 2.40; sports/ recreation 7.52*; street/highway 2.09*; public building 1.57; assisted living/ nursing home 0.03; educational institution 20.85*; other 1.95* (*, reaching statistical significance). Taking the occurrence numbers into considering, the avoiding DALYs attributed by defibrillation were home/residence 3388.91; sports/ recreation 315.66; street/highway; 376.38 educational institution 244.89.

Conclusion:

The effect of defibrillation on DALYs is most obviously in location of education institution. But taking into account the high occurrence numbers in home/residence, the more appropriate place to deploy AED is mass gathering high-rise apartment complex.

Reference:

• Ryan A. Coute, Brian H. Nathanson,  Ashish R. Panchal, etc . Disability-Adjusted Life Years Following Adult Out-of-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12:e004677. DOI: 10.1161/CIRCOUTCOMES.118.004677 

Background:

Spontaneous subarachnoid haemorrhage (sSAH) is a neurosurgical emergency. Clinical characteristics may vary from sudden onset of thunderclap headache or loss of consciousness to diffuse and mild symptoms. The European emergency telephone number 1-1-2 is supposed to be used for potential life-threatening injuries and illness. To assist in the triage, electronic decision support systems such as Criteria Based Dispatch (CBD) is often used.  

We aimed to determine which dispatch criteria were used in patients with sSAH. Secondly, we sought to determine the positive predictive value (PPV), negative predictive value (NPV), sensitivity (SE) and specificity (SP) of these criteria.

Methods:

This was a retrospective cohort study conducted in March 2019. Data were extracted from the Danish National Patient Register on all patients aged 18 years or older, admitted to any hospital in the Capital Region of Denmark between May 1, 2011 and December 31, 2013 and discharged with a primary diagnosis of sSAH. Diagnoses were verified by medical record review. We merged these with CBD data from the Emergency Medical Service Copenhagen (EMS). Proportions, PPV, NPV, SE and SP were reported with 95% confidence intervals (CI).

Results: A total of 200 patients with sSAH were admitted within the study period. Sixty-two had not contacted the EMS. Of the remaining 138 patients, 36 had called a non-urgent medical helpline or ambulances had been requested by general practitioners. Thus, 102 patients had called the emergency number 1-1-2 but complete data were only available in 98 patients. The EMS received a total of 282,898 emergency calls during the relevant time period. The dispatch criterion “thunderclap headache” was recorded in 17 patients with sSAH (17.4%, 95% confidence interval (CI): 10.4-26.3) and 224 patients without sSAH (PPV 7.6% (CI: 4.5-11.9), NPV 100%, SE 17.4% (CI: 10.4-26.3), SP 99.9% (CI: 99.9-99.9)). Any form of severe headache was recorded in 22 sSAH cases (22.5%, CI: 14.6-32.0), (PPV 4.5% (CI: 2.9-7.0), NPV 100%, SE 22.4% (CI: 14.6-32.0), SP 99.8% (CI: 99.8-99.9)). The third most common criterion was unconsciousness, 14 cases. Other stroke symptoms (paralysis, impaired speech or visual disturbances) were found in 13 cases. In addition, a total of 36 other dispatch criteria were recorded including chest pain, seizures, traffic accident, diabetes, intoxication, gastrointestinal conditions, breathing difficulties, and unclear symptoms.

Discussion and conclusion: We found that numerous different dispatch criteria were recorded in patients with sSAH assessed via telephone. Typical symptoms like classic thunderclap headache are not commonly reported and the positive predictive value is low. sSAH should be considered as a possible diagnosis in a variety of patient groups during telephone triage.

ClinicalTrials.gov ID: NCT03786068. Ethics committee approval was not needed. Funding was received from the Danish foundation Trygfonden.

Introduction: Examination of the burnout syndrome in various healthcare fields is of paramount importance for better understanding of the disorder as well as for the establishment of a suitable preventive and intervention program. The emergency departments’ employees are a risk group among healthcare workers, so it is our objective to further expand the knowledge on the characteristics of the burnout syndrome among the Hungarian emergency department staff. Aim of this study is to examine the burnout syndrome and its associations with different variables among the workers of the Department of Emergency Medicine at the University of Szeged moreover to develop and finetune a prevention and intervention training for the medical staff to help coping with everyday stress as well as rise awareness to burnout symptoms.

Method: Cross-sectioned design utilizing a self-administrated questionnaire was used to collect data from the staff (n=72). Burnout was measured using the Maslach Burnout Inventory, while psychological immune competence was measured using the Psychological Immune Competence Questionnaire. Upon data collection a three-round training was developed and implemented after which the measurement of burnout was repeated using the same test battery. We tested the interaction between different variables (age, number of children, years spent in healthcare, weekly number of working hours, number of somatic symptoms, social support and psychological immune competence) and burnout subscales (emotional exhaustion, depersonalization and personal accomplishment) using Pearson correlation. Independent samples t-test was used to compare burnout subscale means in different marital status groups, while Mann-Whitney U-test to compare burnout values between genders. Lastly, the data of the retest was compared using paired sample t-test.  

Results: We found burnout syndrome to be considerably prevalent among the workers especially nurses and physicians (compared to other staff: medical orderlies, medical clerks). Moderate emotional exhaustion was reported both among doctors and the nursing staff. While physicians reported moderate depersonalization, lower personal accomplishment was measured among the nurses. In both, original and post-training study we found a significant correlation between burnout and age, number of children, number of years in healthcare system, number of physical symptoms, social support and psychological immune system. There was no difference between genders, while the workers who were in a relationship reported significantly lower depersonalization. Due to personnel fluctuation we were able to retest only 54% of the original sample, with no change in burnout results. Nonetheless, the data shows the need for individual burnout intervention which presents in significantly stronger relationship with the psychologist as well as in frequency of contact with the psychologist.

Conclusions: The results obtained show correlations and reveal protective and risk factors in burnout which can be key to establishing a preventive and intervention strategies. The training on burnout syndrome rose awareness among the departments’ staff, while personal one to one interventions helped the workers develop individual coping strategies. This data allows us to further develop new institutional intervention techniques. Ethical approval was given by the Ethics Committee of the University of Szeged, with the license number: 122/2017-SZTE (4035).

The work was supported by EFOP 3.6.3-VEKOP-16-2017-00009 grant of University of Szeged, Hungary.

Background

Emergency departments (EDs) play a vital role in the healthcare system either as the freely accessible primary entry point for healthcare or as secondary healthcare referred to by primary healthcare services. Recently, EDs have experienced an increased number of patients including to a greater extent elderly patients with more comorbidity. In addition, some EDs also face decreased available resources (e.g. fewer beds) and crowding in the EDs is now a reality in many countries. It is unclear how these changes affect the ED patient population. We chose to focus on the contribution of short-term ED visits to the ED population and outcome following these contacts.

Aim

Thus, our aim was to investigate 1) the proportion of short-term ED visits (5 hours or less) & 2) the characteristics, diagnoses, patterns of renewed contacts and mortality of patients with short-term ED visits.

Method

Observational cohort study of patients in the emergency departments at three sites in the North Denmark Region 2014-2016. Patients with a valid personal identification number were included. Short-term ED visits defined as 5 hours or less. Primary outcomes were ICD-10 diagnosis chapter, 1- and 30-day mortality and readmissions on days 1 and 2. Data was retrieved from the Patient Administrative System and the Danish Civil Registration System. Descriptive statistical analyses and Kaplan-Meier mortality estimates were performed.   

Results

During 2014-2016, there were 280 365 contacts to the EDs in the North Denmark Region. Of these, we included 134 362 ED visits with duration of 5 hours or less (47.9%). Mean age was 32 (IQR: 16-57), 48.6% were female.

Top five ICD-10 chapters were injury and poisoning N=80 862 (60.2%), other factors N=19 725 (14.5%), symptoms and signs N=15 568 (11.6%), musculoskeletal disease N=3 643 (2.7%) and respiratory disease N=2 413 (1.8%). Overall mortality was 1-day: 0.30% (0.27-0.33), 30-day: 0.74% (0.70-0.79), with the highest mortality among circulatory diseases: 1-day: 10.67% (9.38-12.12) 30-day: 11.94% (10.59-13.46).

Number of renewed contacts on days 1 and 2 after discharge were N=4 696 (3.5%) and N=1 652 (1.2%). ICD-10 chapter from the initial contact for patients with renewed contact on day 1: other factors N=2 522 (53.7%), injury and poisoning N=1 587 (33.8%) and symptoms and signs N=223 (4.8%) and on day 2: injury and poisoning N=951 (57.8%), other factors N=258 (15.6%) and symptoms and signs N=172 (10.4%). Overall mortality for patients with renewed contacts on day 1 or 2 was: 1-day 0.02% (0.00-0.11) and 30-day: 0.43% (0.29-0.62).

 

Discussion and conclusion

Almost half of all ED contacts were short-term visits and predominately due to injuries, which explains the young mean age and low overall mortality. Non-specific diagnoses was the second largest group of patients. Overall, only few patients had a renewed contact within 1 or 2 days. Nevertheless, patients who received non-specific diagnoses during the first admission comprised the largest group of readmitted patients on day 1.

Further research on the non-injury group of patients is needed, in particular the non-specific diagnoses.

 

 

None/ Erika Frischknecht Christensen holds a professorship supported by a grant given by the philanthropic fund TrygFonden to Aalborg University. The grant does not restrict any scientific research.

Background: chest pain is the reason for emergency department (ED) admission in 5-9% of cases. Cardiac origin has been reported in up to 45% of ED admission for chest pain. In our ED there are several predefined panels of laboratory tests that allow to improve and speed up the diagnostic process based on the prevalent symptomatology shown by the patient (for example: chest pain, abdominal pain, sepsis). In our ED we observed an increasing number of high-sensitivity cardiac troponin I (hsTnI) tests in patients complaining of chest pain. We thought that the main reason for this increase was the presence of hsTnI in the predefined chest pain test panel; furthermore, said panel didn’t differentiate between typical and atypical chest pain. The ideal management of patients experiencing chest pain includes not only avoiding misdiagnosis, but also avoiding unnecessary lab tests and therefore inappropriate hospitalizations. Based on lean methodology applied to emergency medicine, in order to further increase the quality and safety of patient care by reducing inappropriate testing, from June 2017 we decided to remove hsTnI from the predefined chest pain test panel.

Methods: we decided to conduct a retrospective, observational, monocentric study with the primary outcome of verifying whether removing hsTnI from the chest pain test panel had led to a reduction in its dosage requests over a six-month period (June-December 2018), compared to June-December 2016 in which hsTnI still appeared in the chest pain test panel. In these two periods of time we first considered the total number of patients admitted to our ED and then those who had admission and discharge diagnoses, according to the International Classification of Diseases, Tenth Edition (ICD-10), compatible with presentation of chest pain; we also considered patients with ICD-10 diagnoses not related to chest pain presentation in which hsTnI testing was requested.

Results: from June to December 2016 ED admissions were 29441 and hsTnI dosage was requested 7021 times (mean value 0.24), in the same six-months period of 2018 admissions were 30182 with 5160 hsTnI dosage requests (mean value 0.17). In 2016 and in the same six-month period cited above, patients with ICD-10 diagnosis compatible with presentation of chest pain were 1728 with 2089 hsTnI dosage requests (mean value 2.21, considering multiple tests in the same patient); in 2018 out of 1697 patients only 1752 HsTnI were requested (mean value 1.03). The same can be seen in patients with ICD-10 diagnosis not related to chest pain presentation: in 2016 out of 26307 admission hsTnI dosage was requested 4932 times (mean value 0.19), in 2018 out of 27034 admissions, hsTnI dosage was requested 3408 times (mean value 0.13).

Discussion and conclusion: the removal of hsTnI from the predefined chest pain test panel led to a decrease of inappropriate hsTnI dosage requests without causing missed diagnoses of acute coronary syndrome (ACS). Applying this kind of methodology probably forced ED physicians to better evaluate chest pain characteristics, EKG findings and patient medical history.

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including from the US the NEDOCS score.

 

Objectives

This study aimed to externally validate NEDOCS in a UK ED setting against expert clinician opinion, and to assess inter-rater reliability between nurse and consultant physician opinions.

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a non-specialist hospital ED in the south of England to calculate NEDOCS values.  The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of NEDOCS cut-offs.  The same method was also used to assess the association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels. To adjust for the effect of temporal correlation (7), further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded 18.53% according to the composite opinion. Median NEDOCS score was 63 (IQR 43 to 85). Weighted kappa score evaluating inter-rater agreement of nurse and consultant opinion was moderate at 0.57 (95% CI: 0.56 to 0.60). AUROC for NEDOCS to predict clinical opinion of crowding was 0.81 (95% CI 0.77 to 0.86)  

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.80 (95% CI 0.73 to 0.88).  

For predicting clinician opinion of risk of harm and safety, AUROCs were 0.71 (95% CI 0.61 to 0.82) and 0.71 (95% CI 0.63 to 0.80) respectively. Higher scores of NEDOCS also correlated with a clinician opinion of insufficient staffing; AUROC was 0.70 (95% CI 0.64 to 0.76).

Optimal performance in our ED was a NEDOCS of >85 with a sensitivity of 59.0% (95% CI 47.7 to 69.7) and a specificity of 82.7% (95% CI 78.5 to 86.5).

Conclusions 

NEDOCS demonstrated good discriminatory power for crowding in our ED.  It also correlated with perception of safety, adequacy of staffing and risk of patient harm.  However further refinement of the score is needed, including the impact of triaged patient acuity-level, which was not incorporated in the original score.  Determining ED specific cut-off point(s) for the score is important, as the previously published thresholds for crowding may not be suitable for all EDs.  This study has demonstrated the feasibility of electronic capture in real time in a UK ED.  

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including the recently derived ICMED. 

 

Objectives

This study aimed to externally validate ICMED in a different UK ED setting to the derivation studies.  Additionally the study aimed to evaluate whether using the full form of ICMED improved the score’s diagnostic ability. 

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a UK non-specialist hospital ED to calculate ICMED values, including calculation of proportion of patients leaving the ED without being seen, the measure omitted from other studies. The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of ICMED cut-offs.  Association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels was also assessed.  To adjust for the effect of temporal correlation, further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded for 18.5% according to the composite opinion. Median ICMED score was 2 (IQR 2 to 3).  AUROC for ICMED to predict clinical opinion of crowding was 0.64 (95% CI 0.58 to 0.70). For predicting clinician opinion of risk of harm and safety, AUROCs were0.60 (95% CI 0.50 to0.70) and 0.59 (95% CI 0.49 to 0.69) respectively. Higher scores of ICMED also correlated moderately with a clinician opinion of insufficient staffing; AUROC was 0.58 (95% CI 0.52 to 0.65)

Optimal performance in our ED was an ICMED of >3 with a sensitivity of 49.4% (38.2 to 60.6) and a specificity of 74.3% (69.4 to 78.7).

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.69 (95% CI 0.59 to 0.79).  However, for ICMED adjustment for temporal correlation required a total of 208 complete observations and 30 crowded observation intervals for adequate power.

  

Conclusions 

This is the first study to validate the full form of the ICMED score.  ICMED demonstrated moderate discriminatory power for crowding (in line with previously published values) as well moderate discrimination for perception of safety, adequacy of staffing and risk of patient harm in our ED.  When adjusted for temporal correlation the AUROC showed a trend towards improvement.  However, the sample size was inadequate to fully account for the effect of temporal correlation.   Further data capture is currently underway to address this.  This study has demonstrated the feasibility of electronic capture of all the parameters of the ICMED score in real time in a UK ED.  

Background:

Emergency department patient complaints are often justified and may lead to apology, remedial action or compensation. The aim of the present study was to analyze emergency department patient complaints in order to identify procedures or practices that require change and to make recommendations for intervention strategies aimed at decreasing complaint rates.

Methods:

We undertook a retrospective analysis of patient complaints from a tertiary hospital emergency department from 2010 to 2018. Data were obtained from letters of response to patient’s complaints. Ethics committee of the Erasme hospital approved the study and waived informed consent.

Results:

349,714 patients were seen in the emergency room from 2010 to 2018, of whom 74,944 (21.4%) were hospitalized. In addition to this number, there are 18,206 patients (5.2%) who leave the emergency department without being seen due to department overcrowding. 279 written complaints (0.08%) were sent to the medical management of the hospital, the mediation service or directly to the emergency department. The median age of patients associated with a complaint was 33 (18-53, IQR; 0 to 80, range) years, with M:F ratio = 0.47. Among the complaints 23.5 % concerned the diagnosis, 22 % invoices for hospital care, 18 % communication with the medical doctor, 16 % the length of the waiting time, 10.5 % the treatment itself, and 10 % the nurse’s communication.

Discussion & conclusions:

Over the observation period, the yearly number of written complaints remained stable at less than 0.1 % of total number of the ED’s patients. More than 50 % of the complaints concerned a wrong or inadequate diagnosis, invoice for hospital care, and communication with the medical doctor. As a remedial measure, meticulous patient care and communication skills workshops for emergency department doctors and nurses will improve patient’s satisfaction and quality of care in the ED.

Trial registration. The study was not registered because there was no appropriate register. Funding. This study did not receive any specific funding.

BACKGROUND: the length of stay (LOS) in the Emergency Department (ED) is one of the causes of the overcrowding condition that currently affects most European EDs. As demonstrated in the literature, the LOS of ED patients is increasing and will increase in the coming years. A longer LOS leads to more significant crowding, poorer functioning of emergency services, increased risk of mortality and exponential cost increases. The heterogeneous morbid conditions combined with the increasing comorbidities presented by patients, force an in-depth diagnostic in many cases. It has been proved that 2/3 of patients accessing ED need an instrumental assessment and 1/3 need blood analysis. The patient's diagnostic path strongly influences the LOS.

OBJECTIVES: to verify whether sending blood samples during the triage process can decrease the LOS and the duration of the medical examination in patients with green and yellow code according to the Manchester Triage System (MTS).

METHODS: a retrospective observational study was performed from January 2018 to January 2019. All patients with a minor code (green and yellow) who needed blood sample for further diagnosis were considered. Patients who performed blood sampling during the TRIAGE evaluation were compared with those who performed blood sampling during the medical visit. Moreover, we calculated and compared the LOS and the time between the start of the medical evaluation and discharge of the two groups of patients. The anamnesis, clinical and severity characteristics documented at the time of triage were recorded.

RESULT: during the study period, 15.596 patients were enrolled. LOS was lower in the group of patients with triage blood sampling with a median of 154 minutes (100 - 231) compared to 172 (119 - 246) in the control group (p< 0.001). Overall, the triage blood sampling group was older, with greater comorbidity and with a more severe clinical condition. A propensity score matching was performed to obtain two homogeneous groups. After statistical matching, LOS remained lower in the triage-sampling group of patients (151 versus 175 minutes, p<0.001). In the adjusted multivariate model, the triage blood sample was found to be an independent factor of decrease of the LOS with standardized coefficients β = 0.857 (0.822 – 0.894, p<0.001). After propensity score matching, we also evaluated the duration of the triage, obtaining an equality of triage times both if the blood sample was taken in triage or during the medical examination, the total duration of the triage lasted 4 minutes.

CONCLUSION the execution of blood samples by the triage nurse reduces the LOS of non-urgent patients in ED and significantly reduces the duration of the medical examination.

Background. Medication errors (MEs) and other drug related problems (DRPs) are common issues on hospital admission. These MEs and DRPs can cause preventable adverse drug events (pADEs) resulting in patient harm with a significant additional cost. A clinical pharmacist (CP) dedicated to the Emergency Department (ED) can improve medication safety by performing medication reconciliation and review, and hence avoid additional costs.

Objective. The aim of this study was to determine the economic value and the cost-benefit of a CP in the ED by applying a theoretical model (University of Sheffield School of Health and Related Research – SCHARR¹).

Setting and Methods. This retrospective, single-centre, observational study was carried out in the ED of a tertiary care university hospital. Since October 2016, 1 FTE CP is dedicated to the ED. Patient-specific recommendations recorded by the CP during a 1 month period were observed. On admission to the ED, the CP had carried out a standardized medication reconciliation and medication review in order to determine pADEs. The most important pADE for each patient was selected and classified for its potential to cause harm using severity rating methods. An expert panel of senior ED physicians evaluated the pADEs for clinical significance. The net cost avoidance was calculated according to the SCHARR model¹. We took into account the lower cost limit of the SCHARR model and current inflation. Statistical analysis was done using Graphpad Prism^® and Microsoft Excel^®.

Results. During 1 month (18 weekdays), the CP recorded recommendations for 136 patients (>18 years) admitted to the ED. On ED admission, medication reconciliation was performed for 98 patients with a median of 4 (IQR 2-7) discrepancies/patient. A medication review for both chronic medication and medication prescribed at hospital admission was performed (n=109 and n=98 respectively). Only the CP’ interventions leading to the most important pADE for each patient were taken into account for the calculation of the cost avoidance. We classified 18 (14.8%) DRPs, 66 (54.1%) DRPs, 37 (30.3%) DRPs and 1 (0.8%) DRP as a pADE with minor or no harm, significant pADE, serious pADE and at least as a severe, life-threatening or fatal pADE, respectively. According to the SCHARR model, this contributed to a net cost avoidance of €40 940. We documented 5 (4.1%) discrepancies without DRP, 53 (43.4%) discrepancies linked to a DRP and 64 (52.5%) DRPs without discrepancy with a cost avoidance of respectively €303, €17 734 and €31 003. The benefit:cost ratio was 5.05:1. Furthermore, the pharmacist carried out a total of 722 interventions.

Conclusion. A CP, integrated in a multidisciplinary ED team, has an important economic value. Furthermore, the CP enhances medication quality and safety by preventing discrepancies in the chronic medication and by the identification of DRPs on admission at the ED.

¹ Campbell F, Karnon J, Czoski-Murray C, et al. A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital. Report for the National Institute for Health and Clinical Excellence as part of the Patient Safety Pilot. 2007

Background:  Poison control centers (PCs) are an essential component of the healthcare system and providing clinical management and improving patient outcomes in cases of toxic exposures. PCs have also demonstrated utility in decreasing the healthcare costs by reducing the use of emergency medical services and length of stay in hospitals. Apart from the clinical expertise, PCs also provide valuable information regarding drugs including medication identification, dosage, interactions, storage, and disposal. This study analyzed the trends in exposure calls received by the PCs from emergency departments (EDs).  

Methods: The case management software, Toxicall, was queried for human exposure calls from EDs between 2016 and 2018. We descriptively assessed the relevant demographic characteristics. Trends in call frequencies and rates (per 100,000) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2016) were reported with the corresponding 95% confidence intervals (95% CI).

Results: The regional poison center serves over 2.4 million people and 45 hospitals within Southwest Virginia, with the specialists handling an average of 58,000 calls every year. Between 2016 and 2018, there were 9,767 calls that were received from the EDs, with 74% of these reporting an acute exposure to a toxic substance. Most exposures occurred at the patients’ residence (87.2%). Females (54%) were predominant in this sample. Among the cases, 23.1% were children under 6 years of age while 8.2% were individuals above 60 years of age. Unintentional reasons accounted for 47.9% cases, while suspected suicides were responsible for 36.2% calls. Ingestion (77.6%) was the most common route of exposure followed by inhalation (7.2%). Unintentional reasons accounted for majority of cases under 6 years of age, while intentional reasons caused 83% of teenage exposures. Intentional exposures were more common among the adult age groups. Serious adverse events were uncommon in our sample, with 10% cases exhibiting major clinical outcomes and only 10 fealties reported in the 3 year study period. Neurological (28.9%) and cardiovascular (19.4%) effects were most pronounced. Approximately one-fourth of the patients were admitted to the psychiatric facility. Exposures to pharmaceuticals like acetaminophen (7.6%) were frequent. Exposures to alcoholic beverages (8%) were also common. Fluids and IV were used as a therapy in 40% cases. While the frequency of calls received by the PC from EDs decreased from 3,461 in 2016 to 3,302 in 2018, the rate of such calls per 1,000 calls received by the PC increased significantly by 5.7% (95% CI: 2.3%, 8.7%, p<0.011) from 169.9 to 179.6 during the study period.     

Conclusions:  Rate of calls received by the PC from EDs during the study period increased. The PCs, a reliable source of information, are being increasingly utilized for the management of complex poisoning cases. PCs provide the EDs with immediate access to the experts who can help in the diagnosis, management, and treatment of toxic exposures and drug overdoses. This triage of cases ensures an optimal level of care leading to reductions in hospitalizations and improving the quality of healthcare.

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