Introduction

Acute cholecystitis is an incidental biliary disease and a frequent reason for emergency room visits. Its incidence is high with a significant socio-economic impact. The number of cholecystectomy in France is increasing.

The main objective of our study was to evaluate compliance with the recommendations of the High Authority for Health (HAS) 2013 and the Tokyo Guidelines 2013 (TGL13) in the management of patients diagnosed with Acute Cholecystitis in our French University Hospital.

Material and methods

We conducted a monocentric, retrospective and observational study including all adult patients for whom a diagnosis of Acute Cholecystitis was carried in the emergency department of our French University Hospital, between January 1, 2016 and December 31, 2016. The population characteristics have been described and the diagnostic and therapeutic course of these patients has been compared with the French recommendations of HAS 2013 and the Japanese Guidelines (2013).

 

Results

A total of 70 patients were selected including 37 men (53%). The mean age was 70 ± 17 years and 65 patients had a follow-up of more than 1 year. The most common comorbidity was hypertension (40%) and 20% were diabetic. Forty-three percent of patients consulted less than 24 hours after the onset of symptoms and almost two-third in the first 72 hours. Cholecystectomy was performed in 52 patients (74%) of whom 49 (94%) were laparoscopic. Surgery was performed less than 24 hours after admission for 29 patients (56%) and was performed in the first hospitalization for 42 patients (81%) with a median time of 1 day [IQR : 0-2 ].

Thus, 71% of patients received a management in accordance with french recommendations and only 54% according to TGL13. Respectively, 95% and 88% of patients out-of french and TGL13 guidelines were justified and recorded in the medical file. The cumulative duration of the two hospitalizations for patients operated later was twice that of the patients operated in the first time of hospitalization (4 days [3; 9] vs 8 days [6; 14], p = 0.0361).

The duration of hospitalization of patients operated without TGL13 recommendations was significantly greater (11.6 days vs 5.4 days, p = 0.0021), the intraoperative complications significantly more frequent (56% vs 25%, p = 0.029), as well as the recurrence rate (53% vs 7%, p = 0.009). For 14 patients (27%), post-operative complications occurred, with no significant difference in terms of non-compliance with recommendations. Eleven deaths were recorded during the follow-up period, 3 (4.6%) related to the biliary pathology.

 

Conclusion

 

In our center, the recommendations of the HAS and TGL13 are generally respected. If necessary, the justification of the therapeutic approach and almost always drawn in the medical file. Failure to comply with these recommendations is associated with an increase in complications, particularly intraoperative complications, length of hospital stay and recurrence rate.

The update of the Tokyo Guidelines in 2018, taking into account the general condition and co-morbidities of the patient at admission, may be more appropriate for our population, whose average age is high and comorbidity existing series.

Objective: An association between bacteriuria and adverse pregnancy outcomes has been extensively described. The current practice of screening all pregnant women for bacteriuria has been challenged by recent studies. We aimed to evaluate pregnancy outcomes among women with positive urine culture and to assess the significance of positive urinary nitrites in this setting.

Methods: Retrospective cohort study conducted between 2014-2018 at the emergency department(ED) of Helen Schnider women center, Israel. Included all Gravida women >18 years old within 20^st week of pregnancy or above admitted to the ED with diverse complains, who had urinalysis collected and subsequently a positive urine culture. Clinical and obstetrics’ characteristics were stratified by positive vs. negative nitrites in urinalysis. The primary outcome was premature delivery and the secondary outcomes were composite outcome of all recorded pregnancy complication and the significance of urinalysis in predicting UTI.

Results: Overall, 874 pregnant women with positive urine culture were included. Of them 721(79%) patients had negative nitrite in their urine exam(NNU-group) and 153(21%) patients had positive nitrite in their urine exam(PNU-group). E.coli was the most common pathogen, with significantly higher rate of growth in the PNU-group vs. NNU-group (129(84.3%)vs.227(38.4%), p<0.001). premature delivery was recorded with no association to symptomacity or nitrite status. Among symptomatic women with classic symptoms of UTI, PNU was significantly associated with decreased risk for major peripartum complications((OR with 95%CI of 0.22(0.05-0.94)).

Conclusions: Our findings support that PNU among symptomatic pregnant women with UTI-related symptom was associated with lower risk to develop major adverse obstetrical outcome.

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Background

Although lower respiratory tract infection is one of the most common cause of death worldwide, at present mortality risk stratification for mortality in patients admitted to the Emergency Department (ED) with pneumonia is not identified adequately using currently available risk scores like CURB65 and PSI: the former has a low sensitivity, the latter a low specificity. 

Aim 

The purpose of this study was to identify the main features associated with mortality within one month in patients admitted to the ED for pneumonia. We focused both on the main predispositions, comorbidities and on clinical and laboratory data.

Methods:

We started from a prospective study in which we evaluated all patients admitted for infection of any origin (a total of 542 patients) between March and June 2017 in San Paolo Hospital and Niguarda Hospital in Milan; then we focused on patients admitted for pneumonia (diagnosis based on clinical and radiological criteria), and at the end we considered the main features related to mortality in this specific subgroup. 

Results:

There were 214 patients admitted for pneumonia (62.1% males): among them, 181 were discharged from the hospital and 31 died (14.4%). The features related to mortality were: age (71.2 vs 82.7 years, p<0.001), being bedridden (18.1% vs 51.6%, p<0.001), use of antibiotics in the previous month (32.4% vs 54.8%, p<0.01), a recent hospitalization (less than a month before) or coming from a nursing home (15.5% vs 32.2%, p<0.05) and serum creatinine levels (1.2 mg/dL vs 2.1 mg/dL, p<0.001). Moreover, a qSOFA ≤2 on arrival in ED had a high specificity (91.1%) predicting a better outcome.

Conclusions:

Patient’s predisposition (age, recent use of antibiotics or hospitalization and coming from a nursing home), qSOFA, renal function and being or not bedridden could be relevant features to achieve a more accurate early risk stratification for mortality in patients admitted to ED and hospitalized for pneumonia. Further studies and a larger sample will be needed to confirm our results.

NCT03601767

Background:

Seasonal Influenza is a common pathology leading to a surge in patient visits in ED.  The diagnosis is usually clinical with association of fever, headache, asthenia and respiratory tract involvement symptoms. The main complications are pneumonia and can lead to acute respiratory distress syndrome and underlying chronic illness decompensation. Isolation measures and single-room admission are needed to avoid transmission. PCR for respiratory virus analysis is performed in another center and results are available 24 to 72 hours after the sample was made.

The aim of this study was to evaluate the impact of a rapid influenza POCT.

Patients and method:

It’s a prospective, observational, monocentric study from 15/01/2018 to 05/02/2018. We assessed a rapid influenza POCT by immunochromatograhy system.  One hundred kits were available. Two nasal swabs were collected; one for the POCT and the second one for PCR test. The indication was left to the physician decision, however the recommendations were: patients who needed admission to the hospital or when the rapid result could change the patient managment.   

Results:

During the study period, 3784 ED visits were recorded. Among the 100 available tests, 97 were interpreted. The mean and median ages were respectively 69.7 and 75 year old [22-101]. 36 patients (37%) had influenza diagnosis, 13 influenza A and 23 influenza B, confirmed with PCR test. The diagnosis with POCT failed for 21 patients: one false positive and 20 false negatives (52% of influenza cases).The sensibility, specificity, positive predictive value and negative predictive value were respectively 44, 98, 94 and 75%. 6 patients had a respiratory syncytial virus infection. Among patients with influenza confirmed diagnosis, 3 had association of fever, sudden onset, asthenia and respiratory symptoms, 19 had fever and respiratory symptoms, 2 isolated fever. 19.4% had influenza vaccine. Leucocytes were increased (>10 000 /mm3) in 39% of patients, CRP was upper then 50mg/l for 10 of 25 patients who had the test and 5/15 PCT were superior to 0.5 µg/l. Among patient with positive POCT, 37% had an antibiotic prescription versus 75% when the test was wrongly negative and 87.5% versus 0 had oseltemivir prescription. 13 patients with positive rapid test were admitted (81.25%) with a length of stay of 9.92 days and 18 patients (90%) with negative POCT and PCR secondary confirmed influenza diagnosis with a length of stay of 10 days.

Discussion:

Influenza diagnosis is usually an association of symptoms during epidemics. In elderly population, clinical presentation is uncommon with high risk of complications. Rapid diagnosis is useful to plane isolation measures. Antibiotic prescription increases in case of non-contributive test. Regarding the test assessment, due to its low sensibility, we didn’t use it during the 2018-2019 season and decide to use a rapid molecular test (isothermal nucleic acid amplification technology).

Conclusion

Rapid influenza diagnosis for admitted patients has an organizational impact. This affects the antibiotics and oseltamivir prescriptions. A test with good sensibility is required.

Background

For patients suffering from an out-of-hospital cardiac arrest (OHCA), having an initial shockable rhythm is a marker of good prognosis. As such, it has been suggested as one of the main selection criteria for extracorporeal resuscitation (E-CPR). However, the prognostic implication of converting from a non-shockable to a shockable rhythm, as compared to having an initial shockable rhythm, remains uncertain, especially among patients that can otherwise be considered eligible for E-CPR. The objective of this study was to evaluate the association between the initial rhythm and its subsequent conversion and survival following an OHCA, for the general population and for E-CPR candidates.

Methods

This study used a registry of OHCA in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the initial rhythm was known were included. Patients were considered E-CPR candidates if they met the following criteria: less than 65 years of age, witnessed collapse and bystander cardiopulmonary resuscitation, no return of spontaneous circulation after 15 minutes of prehospital resuscitation. The primary outcome measure was survival to hospital discharge. The association of interest was assessed using a multivariable logistic regression, if appropriate. If not, it was planned to perform only univariates analyses using a Chi-squared test or a Fisher’s exact test, as appropriate.

Results

A total of 6681 patients (male=64%, mean age=70 years [standard deviation {SD}=17], survival=11%) were included, of whom 1788 (27%) had an initial shockable rhythm, 1749 (26%) had pulseless electrical activity (PEA) and no subsequent shockable rhythm, 295 (4%) had PEA and a subsequent shockable rhythm, 2694 (40%) had asystole and no subsequent shockable rhythm, and 155 (2%) asystole and a subsequent shockable rhythm. As compared to patients having an initial shockable rhythm, patients in all other groups had significantly lower odds of survival (adjusted odds ratio [AOR] between 0.15 [95% confidence interval {CI} 0.12-0.18] and 0.017 [95%CI 0.010-0.030]; p<0.001 for all comparisons). Among patients with a PEA and asystole, there was no association between evolving to a shockable rhythm and survival to hospital discharge (AOR=0.74 [95%CI 0.40-1.35], p=0.32, and AOR=1.37 [95%CI 0.17-10.83], p=0.77, respectively). A total of 556 (male=73%, mean age=53 years [SD=10], survival=18%) patients were considered E-CPR candidates according to their clinical characteristics. Among these patients, 248 (27%) had an initial shockable rhythm, 175 (31%) had PEA and no subsequent shockable rhythm, 26 (5%) had PEA and a subsequent shockable rhythm, 76 (14%) had asystole and no subsequent shockable rhythm, and 5 (1%) asystole and a subsequent shockable rhythm. Given the small number of patients and events in some groups, only univariate analyses were performed. Patients with an initial shockable rhythm had better odds of survival than patients in all other groups (p<0.001 for all comparisons). No other comparisons yielded significant results (p=0.09 to p=0.80).

Conclusions

There is no clinically significant association between the conversion to a shockable rhythm and survival in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.

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

Background:

In patients with acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) exacerbation, non-invasive ventilation (NIV) is strongly recommended as first line treatment able to improve pH, reduce respiratory rate, prevent immediate intubation and improves survival. In stable COPD patient the rationale of use of high-flow nasal cannula (HFNC) is providing warm and humidified air, reducing transcutaneous carbon dioxide (CO₂) and decreasing work of breathing.

Nevertheless, weaning protocol after NIV are not so well defined.

In this study we observed the difference between the use of HFNC versus low oxygen flow treatment (LOFT) in patients with COPD exacerbation after a period of NIV. The aim was to determine if HFNC reduces the need to return to NIV compared to LOFT during the weaning period. In addition, we observed how vital signs and blood gases changes along the recovery time.

 

Methods:

This is a prospective randomized study. We enrolled 28 patients with ARF due to COPD exacerbation treated with NIV from January 2018 to May 2018. NIV started in emergency room (ER) and when NIV support ended, patients were randomized 1:1 between HFNC and LOFT, based on the availability of HFNC (AIRVO® 2 Fisher and Paykel) at the time of randomization.

HFNC therapy was applied at a flow of 60 L/min and minimal FiO2 to maintain an oxygen saturation of 91% or more. LOFT was applied through nasal cannula or face mask to reach the same target.

SO2 and pO2 were significantly higher in HFNC than in LOFT group (p=0.030 and p=0.054 respectively). Besides, respiratory rate was significantly lower at 60 m in the HFNC group compared to LOFT group (p=0.0173).

 

 

 

 

Results:

Eight (29%) of all patients returned to NIV, 1(8%) in the HFNC and 7 (47%) in the LOFT group respectively (HR 7.5 – p=0.060). Patients in the LOFT group returned to NIV sooner than those in the HFNC group.

 

 

Conclusions:

As main result, we observed that HFNC reduces the need to return to NIV during the weaning period in patients with ARF due to COPD exacerbation. Regarding the time between the two cycles of NIV, we reported a shorter time in patients treated with LOFT. This is of great value in order to assess standard protocol of weaning from NIV in patient with COPD exacerbation, in which often the length of stay is affected by the need of prolonged ventilation.Ethical approval and informed consent are not needed due to the type of study.

Backgrounds: The characteristics of OHCA patients are very diverse, and the potential benefits and risks of PCA care may not be the same among subgroups. We hypothesized that there were some interactive effect of PCA care on survival and neurological outcome after OHCA was observed across patients depending on the use of mech-device. This study aimed to investigate whether use of mech-device has any impact on the neurological outcomes of PCA care.

Methods: This study is a cross-sectional study using a nation-wide registry database of OHCA in Korea. The OHCA registry began in 2006 in collaboration with the Korea Centers for Disease Control and Prevention (CDC) and the National Emergency Management Agency (NEMA) of the Republic of Korea government to improve the outcome of cardiovascular disease in Korea.

The data were extracted between January 2016 and December 2017. The inclusion criteria were all OHCA adults who are older than 18 years with presumed cardiac etiology and survived to admission. Patients were excluded who achieved return of spontaneous circulation (ROSC) at the scene, those with cardiac arrest that occurred in the ambulance, and patients with missing information on neurological status at hospital discharge. The primary outcome was favorable neurological recovery at hospital discharge, defined as a cerebral performance category (CPC) of 1 or 2, [14] and the secondary outcome was survival to discharge.

Results:

After adjusting for other covariates in the interaction model, the aOR of TTM and CRT for survival to discharge was no different in patients with use of mech-device (aOR 2.28, 95% CIs 0.81-6.45, aOR 3.76, 95% CIs 1.44-9.80), respectively) and patients without use of mech-device (aOR 1.08, 95% CIs 0.76-1.54), aOR 8.02, 95% CIs 6.09-10.57), respectively). For good neurological recovery, the aOR (95% CIs) of TTM and CRT were 2.41 (1.90-3.06) and 3.40 (2.79-4.14) in patients without use of mech-device whereas the effect was statistically non-significant in patients with use of mech-device with aOR (95% CIs) of 1.89 (0.97-3.68) and 1.54 (0.79-3.01) (Table 5).

Conclusions:

Use of mech-device modified the effect of PCA care on neurological outcomes for OHCA patients. PCA care is significantly associated with good neurological recovery in non-mech-device group, but not in mech-device group in Korea.

Introduction

Cervical collars, immobilization devices applied in the pre-hospital setting by ambulance staff following a trauma, are not without risk. Some of these short-term risks include patient discomfort, complicated airway management, and increased exposure to radiation. Clinical decision-making algorithms such as the Canadian C-Spine rule and the National Emergency X-Radiography Utilisation Study (NEXUS) criteria were created and validated to support the safe removal of this devices in alert, orientated and low risk adult trauma patients. The aim of this systematic review is to assess whether appropriately trained nurses working in the emergency department can safely remove cervical collars using cervical spine rules in low risk adult trauma patients.

Methods

We conducted a systematic review of the existing literature searching PubMed/MEDLINE for studies that investigated clearance of c-spine immobilization with validated criteria in low-risk trauma patients by emergency nurses. 

Results

We identified 8 research articles. Emergency nurses used the Canadian C-Spine rule to remove the collar in six articles and the NEXUS criteria in the remaining two. Five articles assessed the inter-rater reliability between nurses and physicians on cervical collar removal. Of these, four reported a kappa statistic ranging among studies from 0.60 to 0.78 indicating a substantial agreementand one study reported an agreement of 94.3% indicating a strong agreement. Two articles demonstrated a reduction of the time patients spent in the ED with a cervical collar and one a reduction of length of stay in the ED.  As investigated in five studies, ED nurses were confident in applying a cervical spine clearance protocol. 

Conclusions

Trained ED nurses can safely remove cervical collars in alert, orientated, low risk trauma adult patients by using validated algorithms like the Canadian c-spine rule or NEXUS criteria. Adoption of these algorithms improves the flow of patients and may reduce wait times in the emergency departments. Also, nurse clearance of c-spine reduces radiations and time spent by patients with cervical collars leading to less discomfort and pain. Implementation of a nurse c-spine clearance protocol should be accompanied by appropriate training and continuous supervision over time looking for cases of missed injuries.

After a departmental teaching session it was identified that there was a gap in knowledge, among various members of staff across a range of grades, in regards to the appropriate advice to give patients who had presented to the emergency department with a head injury. In particular on the issue of driving after a head injury. A study carried out in 2010 by Headway showed 35% of EDs in the UK failed to give out advice on post concussion syndrome. Given around 1 million people present to ED with a head injury each year in the UK this would result in a significant number not receiving adequate medical advice; this could potentially lead to further accidents and injuries or really in a patient driving while uninsured. While our department has a post head injury leaflet to give to patients this leaflet contains no advice regarding driving. 

Our emergency department is split across two sites at District general hospitals in the West of Scotland caring for both adult and paediatric presentations.

A search of electronic records was carried out for all patients presenting to the ED over the course of one week in December 2018 using the diagnostic codes for head injury, head wound and concussion. The notes were reviewed looking for evidence that the patient had been advised not to drive if they had persistent symptoms of a head injury and whether they received the ED's written advice on head injury. 

This showed that no patient had been advised not to drive while they had ongoing symptoms of a concussion. However almost every patient had received a head injury leaflet. 

The intervention was to update the leaflet with appropriate advice on driving after a head injury and to alter the head injury proforma to include driving advice in the discharge checklist. Members of staff in the department were provided with teaching and informed of the updated leaflet. 

The same search was carried out following the teaching for a one week period in May. This demonstrated that > 80% of patients now received adequate advice.

Ensuring we give our patients the best and most accurate advice for management of post concussion syndrome is vital to empower them to make the best choices for their health and wellbeing. 

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INTRODUCTION:Traffic accidents have been a bleeding wound due to developing technology and increasing number of vehicles.High costs appearby tests and treatments as well as further health problems and loss of labour power in traffic accidents.The aim of the study was to assess the costs of traffic accidents from first referral to emergency department through anatomic scoring and to search the effect of traffic accident pattern and anatomic scores on the costs.METHOD:The study was conducted through retrospective review of hospital automation system, juridical records and patient files of the patients who referred our hospital between December,1,2018 and February,28,2019. 651 patients whose records were complete were enrolled into the study.Conformity test was performed for all variables to normal distribution;Kolmogorov Smirnov test was run to asses the conformity to parametric test criteria.The data obtained in the study within the scope of clinical research have a non-parametric quality in terms of
statistics.Therefore, Kruskal-Wallis H tests were used for statistical evaluation of associated variables according to dependency status.FINDINGS:The patients enrolled into the study included 457 males and 194 females with an age average of 33.89.The patterns of traffic accidents were intra-vehicle traffic accident by 31.2%,extravehicular traffic accident by 50.5%,motorcycle accident by 18.1%.Injured body site of the patients were lower limb by 45.3%,upper limb by 35.9,head by 30.7% and face by 19%, respectively.GCS, AIS and ISS scores were grouped for statistical calculations.Evaluation of patient outcomes revealed discharge in a healthy state by 88.8%,admission to the clinic by 8.6%, admission to intensive care unit by 2% and exitus by 3%.Mean cost of traffic accidents was found 247,38TL.The effect of traffic accident pattern on the cost was not statistically significant.The effect of clinical outcomes on the cost was found statistically significant.There was a statistically significant effect of GCS,AIS,ISS trauma scores on the cost.A correlation test was performed in the study to detect a significant conformity between traffic accident patterns,clinical outcomes,trauma scores and cost.There was not any significant association between traffic accident patterns and cost.The association between clinical outcomes and cost was weakly significant. A positively weak association was found between the cost and GCS. The association between AIS and ISS and the cost was moderately significant and a positive correlation was found.DISCUSSION:Traffic accidents are one of the basic causes of death among younger population below 50 years of age. Traffic accident patterns were evaluated in terms of AIS and ISS efficiency and correlation.There was not any difference between test and treatment costs and traffic accident patterns when efficiency of traffic accidents was evaluated on costs.Costs increase by increase of AIS and ISS scores.Clinical outcomes are also effective on the cost.CONCLUSION:Traffic accidents usually cause multi-traumas and costs of the tests and treatment services are detected higher.The association and correlation between trauma scores and cost were evaluated; and costs increase by increase in numeric data of the trauma scores.An increase in costs were detected according to the clinical progress of the patients. We believe that trainings should be increased to reduce traffic accidents for health as well as country economy.

INTRODUCTION

Acute kidney injury (AKI) following trauma has been shown to be associated with significant morbidity & mortality. We carried out a retrospective study in order to examine epidemiology and outcomes of AKI in an Irish population. 

  

METHODS

Major trauma patients attending a tertiary referral university hospital with an annual ED census of approximately 56,000 between 01/09/13 and 31/12/15, who were included in the Trauma Audit and Research Network (TARN) database and for whom more than one laboratory creatinine value was available, were eligible for the study. The primary outcome measure was AKI diagnosed during admission or within 30 days of arrival to hospital. AKI was defined as per the Acute Kidney Injury Network (AKIN) criteria. A logistic regression analysis was performed to identify factors associated with the development of AKI. 

  

RESULTS

967 patients were included, 487 (50.9% were male). 116 patients (12.0%) developed AKI during the study time period. The mean age of the AKI group was 75.97 years (standard deviation (SD) 15.36) compared to 62.19 years (SD 22.18) for the non-AKI group. The AKI group had a higher mortality rate (10% vs 3%) and ICU admission was more common (16% vs 7%). Hospital length of stay was longer for the AKI group (46.2 vs 18.9 days, p<0.0001). There was no significant difference in the incidence of shock or in injury severity scores (ISS) between the two groups. 

  

DISCUSSION

The incidence of AKI in our study group was similar to previously reported studies. AKI was shown to be associated prolonged length of stay, an older cohort of patients and increased mortality. No association was shown with shock or ISS. The findings of this study should alert treating physicians to the increased incidence of AKI in older trauma patients and to its potential effect on hospital stay and mortality. 

 

Background and Objectives

Originally pioneered by Augusto Boal, Forum Theatre (a technique of Theatre of the Oppressed) uses interactive drama to explore challenging encounters in a shared group environment. It promotes wider reflection and allows individuals to explore and rehearse solutions in a ‘safe environment’, empowering participants to address oppressive situations in real life. 

Burnout and job dissatisfaction are well documented amongst staff members working in the Emergency Department (ED). Contributing factors include challenging interpersonal interactions and a lack of administrative and clinical autonomy. Measures of staff wellbeing correlate positively with patient satisfaction and are associated with reduced adverse clinical outcomes. We explored the application of Forum Theatre methods in empowering ED staff to better handle challenging encounters in the workplace.

Methods

A mixed disciplinary group from an ED in London attended a four-day course to learn the methods of forum theatre. Participants used their own experiences to write and perform two scenarios depicting workplace oppression to an audience of hospital staff. Themes, outcomes and the potential for change around the scenario were discussed by the audience and audience members assumed the role of the protagonist in the scenario to put audience suggestions into practice.  

Results

Participants (n= 10, all female, average age 31) all stated that they sometimes felt they had no power or choice at work. All felt that it was important to do fun activities at work and that their wellness was important to the functioning of the department.

Attendees to the performance (doctors, nursing staff, senior management) found it uniformly enjoyable and useful. Most found that it encouraged them to think about how to handle difficult situations at work (94%).

Conclusions

Forum theatre can empower ED staff to feel more prepared and confident in addressing conflict in the workplace. 

Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.

 

Introduction

Ethanol is one of the leading causes of death worldwide.  Once intoxicated, the risk for trauma increases as the ethanol percentage rises. After valuating reasons for patient flow to emergency department ethanol related visits cover 12 to 15 % in daytime and the frequency rises in the weekend nights nearly to 70 %. Further, ethanol intake can masquerade the real reason for the visit; after the first triage 23 % of the patients have been triaged with a false intake diagnose.

Generally ethanol levels are measured via breathalyzer or intravenus blood sample.

Both options have their weaknesses and cannot be utilized in every situation. Breathalyzer demand a co-operating patient. Patients with lowered consciousness cannot exhale properly. Further, disoriented patients who cannot grasp the concept of long steady exhale cannot be evaluated reliable with breathalyzer. 

The problem with venous sample is processing time. The process can take up to 30 – 90. Thus, it doesn’t help the clinician in the first evaluation of the patient.

To our best knowledge PAL Finland has developed world`s first point-of-care test for ethanol, Albio™. It is patented in EU, US patent pending. Albio™ can analyze blood ethanol concentration during less than 10 seconds from a small sample of blood. The sample can be taken from capillary blood; thus, it is easy and quick to use. In most countries paramedics control blood sugar levels and capillary sample for ethanol levels can be taken from the same sting. Basic operating principles are based on chemical reaction where ethanol and nicotinamide adenine dinucleotide in the presence of alcohol dehydrogenase (ADH) oxidize forming acetaldehyde and oxidized form of nicotinamide adenine dinucleotide.

Objective

Firstly, the device had to be validated by the company. In the second phase independent research team will test the device in the field. The objective is to study whether, the device is accurate enough also in the real life and is reliable/practical to use. The study will start in late 2019 and it is composed by the main author of this abstract (with research team) without any engage from the company. 

Methods and results

We studied the changes of electric current in the Albio™ device in relation to blood ethanol concentration. For ethanol concentration of 0.0 permille, the device gave a certain number of arbitrary units. When ethanol concentration was risen to 0.25 and 0.50 permilles the mean values were 1.84 and 2.31 times higher than for 0.0 permilles, respectively. Further, the mean values were 2.64 and 2.98 times higher for 1.0 and 1.5 permilles than for 0.0 permilles, respectively. The individual values were clearly separable from those taken in other ethanol concentrations.

Conclusion

In the internal validation of the company, the point-of-care blood ethanol device looks very promising. If it holds the results in the coming field test, it will become a useful asset to first responders, paramedics together with doctors and nurses working in emergency departments.

Background: A good feedback should have certain attributes, as cited extensively in the literature.   Appropriate and timely feedback is crucial in improving the clinical practice of the residents. In spite of its importance, the residents regularly express their displeasure with the quality of feedback. One of the important barriers to constructive feedback is a lack of appropriate training and skill of giving feedback.  Accreditation Council of Graduate Medical Education has recommended feedback as a core skill for Emergency Medicine Residents (EMR).

 

Aim/Objectives: The primary aim of the study was to find the most efficient technique of teaching the skills of feedback to EMR. The secondary aim was to gauge their preferred educational technique.

 

Method:  This was a prospective mixed method study that included 45 EMR in the current training program.  A computer-generated block randomization with concealed and opaque envelopes.  All residents were randomized to group A, B and C.  Group A received no prior training, Group B read a brief document about the attributes of a good feedback and group C received one to one tutoring from one experienced faculty about the attributes of a good feedback. A brief 4 minute- teaching video on Rapid sequence intubation (RSI) was prepared by the teaching faculty which was assessed by two senior faculty and approved for this trial Each resident was asked to watch the video and provide feedback on the skills of the physician performing RSI.  An assessment form based on good feedback attributes cited in the literature was created and validated. The feedback techniques of EMR were audio recorded and assessed by two senior faculty blinded to the study. The study was approved by institutional research council and exempted from ethics review. The EMR preference for their preferred educational technique was obtained through a semi structured interview from a group of 7 volunteers. 

 

Results: The baseline characteristics of the three groups were similar.  With Group A set as the baseline, as compared to that baseline Group A score Group B subjects’ total score was 1.3 points higher (95% CI 0.3 to 2.3, p = .014) and Group C subjects’ total score was 2.7 points higher (95% CI 1.7 to 3.7, p < .001).  (Overlapping 95% CIs between Group B and Group C suggested there was no statistically significant difference between those two groups’ total scores). The residents favored self-reading and 1:1 tutoring equally.

 

Discussion: Learning a feedback skill is essential during EMR program. This skill can be acquired through either self-reading an appropriately written document or 1-1 teaching by appropriately trained faculty. The study may also have implications on the utilization of faculty time for teaching core skills to EMR.

 

Conclusion: Compared to Group A, Groups B and C scored significantly higher on the overall assessment and statistically similarly to each other. There was no sign of association between either sex or PGY year or total score.  EMR preference for feedback technique was equally distributed between self-reading and 1:1 tutoring.

Funded by MRC of Hamad Medical Corporation

Background: Cutaneous lacerations requiring sutures remain a common reason for seeking medical care in the emergency. Suturing can cause pain, anxiety and necessitates time to ensure a good outcome. This study assesses if non-invasive Zip wound closure could be a way for Accident and Emergency (A&E) departments to save time as well as improve patient experience. Method: 13 adult and 13 pediatric patients presenting with minor lacerations to their respective A&E departments at the Karolinska University Hospital were randomized to nylon suture or non-invasive Zip wound closure. Closure and overall procedure durations and patient pain (using a Visual Analog Scale (VAS)) were measured. Patient satisfaction, pain and adverse events were recorded via phone interview at 10 and 30 days after treatment. An independent panel of physicians assessed digital photographs of the wounds after 10 and 30 days using the 0-6 Wound Evaluation Scale. Results: Average total treatment time in the pediatric and adult cohorts was reduced 59% (p=0.004) and 62% (p=0.010) respectively in the Zip cases vs. traditional sutures. Patients reported 69% less pain during closure (mean VAS 12.8 and 40.9, respectively), 31% less pain during closure removal and 54% less pain when assessing overall scar pain (mean VAS 9.7 and 20.8, respectively) with the Zip device compared to sutures. Patients treated with the Zip device reported 66% less fear or anxiety during wound closure compared to patients treated with sutures (mean VAS 11.8 and 34.6, respectively). Baseline grading on the Wound Evaluation Scale was an average 4.9 and 4.6 in the sutures vs. Zip cohort. After 30 days the wounds were graded 4.8 and 5 respectively. Conclusion: The Zip device demonstrated reduced treatment time, patient pain and anxiety and increased patient satisfaction in both the pediatric and adult emergency department. Using the Zip device, there was no requirement to use infiltration with local anesthetic and a superior cosmetic outcome after 30 days was seen. Additionally the Zip can also eliminate the need for a suture removal visit, which may save time and overall healthcare cost.

Trial Registration:This is a post-market clinical study using a CE-marked product for its intended used, hence no registration was needed. Ethical approval by Regionala Etikprövningsnämnden (Regional Ethics Review Board) i Stockholm: Zip-009, EPN diarie number: 2017/831-31/1 Funded by: ZipLine Medical, Inc. 747 Camden Ave., Suite A Campbell, CA 95008 USA

Introduction

The UK Trainee Emergency Research Network (TERN) was established in August 2018. To understand the potential of the network, a pilot study was designed to assess the ability of TERN to collect standardised multi-centre data on subarachnoid haemorrhage (SAH). This topic was chosen after competitive review of submitted research questions by Trainees.  Extensive work by Perry showed almost perfect sensitivity of CT within 6 hours in suspected SAH, the results are yet to be adopted into UK clinical practice. It has therefore been listed in the top 20 RCEM/James-Lind Alliance research priorities and adopted as a TERN study.

Methods

Design

Sites were invited to participate via email to Trainees registered with TERN. Sites that registered interest were assessed for data collection completion and levels of data variability. 

Setting

The study was conducted in twenty-two Emergency Departments (EDs) in the UK, that included a mixture of tertiary referral centres and district general hospitals. Retrospective data was collected for patients presenting with a headache between 26/11/2018 at 0000 until 02/12/2018 at 2359. Data entry was open for two months to allow for entry of final diagnosis.

Outcomes

Primary

• Assess feasibility of TERN to collect standardised multi-centre data on SAH.

 Secondary

• Identify number of patients presenting to ED with headaches in a 2-week period.
• Identify number of patients who underwent CT scan within 6-hours of symptom onset.
• Identify number of SAH.

Results

29 sites registered interest in data collection. 24 (82%) sought approval from their hospitals, 2 were denied permission, which left 22 (76%) who collected data.

Data on 403 eligible patients were collected. The average number of eligible patients per hospital was 18.3 (min=5, max=53). Median age was 42 years (Q1-Q3 = 30-56 years). Overall, 68% of eligible patients were female, varying from 43 to 100% between sites. 

A CT scan was performed in 161 (40%) eligible patients, with an average of 7.3 (min=2, max=15) CT scanned patients per hospital. CT scan rates varied from 19% to 100% between sites. Abnormalities were found in 20 (13%) scanned patients, with 3 confirmed SAH (1.9%).

Onset to CT duration was calculable in 105 cases, and under 6 hours for 24 of these (23%, ranging from 0 to 100% between sites). Arrival to CT duration was calculable in 154 cases and was under 6 hours in 135 of these (88%, ranging from 0 to 100% between sites). 

Discussion and Conclusion

Though data quality varied between sites, this pilot study has identified possible improvements that minimise these issues including stricter data validation rules, clearer questions, and prospective data collection. Patient case-mix and treatment practices, including SAH prevalence and CT rates, should be cautiously interpreted as this pilot was not powered to accurately estimate these quantities. A future study is being developed to validate the 6-hour CT head rule based on an improved and expanded data collection process. More generally, this pilot has demonstrated that, with careful planning and execution, TERN is able to collect multi-site data of sufficient quantity and quality to conduct large-scale studies.

Funded by the Royal College of Emergency Medicine

Background

Patients who present to the Emergency Department (ED) of Sligo University Hospital (SUH) with a suspected hip fracture are managed with the aid of the ‘Neck of Femur Fracture (NOF) Pathway’, which is a guide designed to facilitate speedy assessment and transfer of patients to the Orthopedic ward for definitive treatment, while delivering optimum care. SUH guidelines set a target of 4 hours from ED presentation to ward arrival time.

We investigated how efficiently patients with NOF are being managed and transferred from the ED to the Orthopedic ward, while aiming to identify specific points of potential time delay.

Methods

We performed an audit of patients who presented to the ED with NOF between December 2018 and February 2019. Specific parameters included time from arrival to receiving Fascia Iliaca Compartment Block (FB), documentation of agents used in FB and door to ward time. Further categories included documentation of mechanism of injury, pre hospital mobility status, and if an Abbreviated Mental Test (AMT) was performed in the ED.

Results

22 charts were available for analysis. These included 16 Female patients (73%) and 6 Males (6%).  95.5% of injuries occurred due a low energy mechanism. Of the 22 patients investigated, 19 had an FB performed in the ED. The average time from door to FB was 2 hours 16mins. Of the 19 patients who received an FB, 10 (52.6%) had documentation of agents used. All 10 of the documented cases used a combination of Bupivocaine and Lidocaine, with a variation in strength and quantities of these agents. All but one case had documented prehospital mobility status. An AMT was performed in 9 cases (41%). The average door to ward admission time was documented in 18 cases, with an average time of 4 hours and 43mins.

Conclusion/Discussion

The majority of patients are being treated in the ED with FB. There seems to be poor documentation of agents used in the procedure, with a large variation of preferences for particular agents among individual doctors. The time from door to FB of 2hrs 16mins may potentially be improved to facilitate a faster admission to ward time. The target door to ward time is being missed by an average of 43 minutes, which may not necessarily reflect ED delay, and is likely a multi-factorial issue (bed shortages etc). However, the possibility to improve ED management time is evident. Documentation of prehospital mobility is adequate. Our quality improvement plan includes the introduction of ‘Regional Anesthesia Trolley’, which will have all equipment required for a FB in one location, thus reducing preparation time. We have consulted national guidelines to create a standard approach guideline for agents used in FB. We presented our initial audit findings at ED teaching, with emphasis on these factors to help improve overall care of patients suffering NOF. Data is currently being collected to assess any new change in practice post these quality improvement measures being introduced.

 

 

This study did not receive any specific funding