Sunday 13 October
14:35

Sunday 13 October

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EPOSTER 1.1
14:35 - 14:55

ePoster 1.1 - Short Oral Presentation - Screen 1

14:35 - 14:40 #18094 - SP001 Differences between women’s and men’s patterns of revisits in a cardiac emergency department.
SP001 Differences between women’s and men’s patterns of revisits in a cardiac emergency department.

Background: Emergency department (ED) revisits may reflect a non-optimal utilization of services. Patterns of ED revisits in cardiology-specialized hospitals have rarely been reported because of their specificity. Moreover, women and men are known to differ on illness characteristics (e.g. symptoms of heart attack). Our objective was to compare the rate of ED revisits of women and men in a cardiology-specialized hospital at 30 days (primary outcome), and at 90, 180, 365 days after an initial ED visit.

Methods: This was a secondary analysis of a clinical trial testing an ED-to-home transition intervention aiming to reduce ED revisits at 30 days in a tertiary cardiology hospital in Montreal, Canada. Patients discharged home after an ED visit and considered at risk for a revisit (e.g. > 1 previous ED visit in the last year and the use of ≥ 6 medications) were included. The rate of revisit at 30, 90, 180, and 365 days of women and men were compared using chi-squared tests. Multivariate logistic regressions were performed, controlling for age, diagnosis at the initial ED visit (4 categories: chest pain-related, arrhythmia-related, heart failure-related, and other), and antecedents of cardiac (no-yes) and non-cardiac (no-yes) surgery.

Results: A total of 265 patients (56.2% men) were included. Men and women had similar mean ages (66.6 vs 68.0, p=0.28) and triage scores at the initial visit (4.0% vs 6.2% [Priority 2], 52.3% vs 41.4% [Priority 3], 38.3% vs 50.9% [Priority 4], and 5.4% vs 2.6% [Priority 5], p=0.14). Discharge diagnoses were similar in men and women (chest pain: 24.8 vs 25.0%, arrhythmia: 26.8 vs 25.9 %, heart failure: 9.4 vs 7.8 %, “other” problems: 31.8 vs 41.4%, p=0.96). Men had more antecedents of cardiac surgery than women (39.6 vs 24.1 %, p=0.008), but less antecedents of non-cardiac surgery (27.5 vs 57.8 %, p<0.001).  Men had more revisits than women at 30 days (24.8 vs 11.2%, p=0.005) and at 180 days (51.3 vs 38.8%, p=0.028). In the multivariable model, at 30 days, there was significantly more ED revisits in men (adjusted odds ratio [AOR] 2.44; 95% confidence interval [CI] 1.16-5.10). There was no significant sex difference at 90, 180 and 365 days. Among control variables, compared with chest pain-related diagnosis, patients with arrhythmia had more ED revisits at 30 days (AOR 7.01; CI 2.22-22.10), 90 days (AOR 4.19; CI 1.89-9.31), 180 days (AOR 2.74; CI 1.34-5.61) and 365 days (AOR 2.54; CI 1.26-5.11). Patients with a diagnosis of heart failure also had more revisits than patients with a chest pain-related diagnosis at 30 days (AOR 5.62; CI 1.38-20.93), 90 days (AOR 4.30; CI 1.46-12.62), 180 days (AOR 4.38; CI 1.55-12.42) and 365 days (AOR 3.07; CI 1.08-8.72).

Discussion and Conclusions: After controlling for age and illness related-variables, men had more risk than women to revisit the ED at 30 days in a cardiology-specialized hospital. While it is possible to hypothesize that sex differences in illness-related factors (e.g. cardiac symptoms) influence ED utilization, further research is needed to understand other factors that may explain these differences.

Sylvie COSSETTE (Montreal, CANADA), Marc-André MAHEU-CADOTTE, Guillaume FONTAINE, Tanya MAILHOT, Patrick LAVOIE, Alexis COURNOYER, Alain VADEBONCOEUR
14:40 - 14:45 #18325 - SP002 Diagnostic value of Coronary Artery Disease Consortium and updated Diamond–Forrester scores in predicting obstructive coronary artery disease among emergency department patients with chest pain.
SP002 Diagnostic value of Coronary Artery Disease Consortium and updated Diamond–Forrester scores in predicting obstructive coronary artery disease among emergency department patients with chest pain.

Objective Assessing the pretest probability of coronary artery disease (CAD) is crucial for patients with chest pain at an emergency department (ED). Current guidelines recommend the use of the updated Diamond–Forrester (DF) method and Coronary Artery Disease (CAD) Consortium models by the American College of Cardiology/Amercian Heart Association (ACC/AHA) and European Society of Cardiology (ESC), respectively. In the situation which methods or models have not been proved definitely superior over others for assessing it, we studied to compare the performance of these models among patients with chest pain presented in the ED.

Methods We compared three scores (DF, CAD consortium basic, and clinical) among 536 patients with chest pain who underwent coronary computed tomographic angiography (CTA). Invasive angiography was performed to confirm the stenosis shown on CTA, if clinically indicated. Primary outcome was the presence of obstructive CAD (≧50% stenosis).

Results Overall, 174 (32.5%) patients were diagnosed with obstructive CAD. CAD consortium clinical model underestimated the prevalence of CAD (26.1%), and on the other hand, DF model overestimated (53.1%). To predict obstructive CAD, the CAD consortium clinical model had superior area under the receiver-operating curve (0.754), followed by the CAD consortium basic (0.736), and finally, the DF model (0.718). Whereas the CAD consortium models more accurately classified patients without any CAD or nonobstructive CAD as low-risk patients, the DF model more accurately classified high-risk patients with obstructive CAD. The net reclassification improvement of CAD consortium basic and clinical models were 15.3% and 18.0%, respectively.

Conclusion Compared with the DF model, the CAD consortium clinical model appears to be superior for the prediction of low-risk patients with <15% probability of having obstructive CAD. However, this model needs caution when using in high-risk population.

Yosep SHIN (SEOUL, KOREA), Ahn SHIN, Un Woo LEE
14:45 - 14:50 #18822 - SP003 Multilevel Prediction model of acute myocardial infarction in chest pain patients of emergency department.
SP003 Multilevel Prediction model of acute myocardial infarction in chest pain patients of emergency department.

Background

Prediction models have been developed for acute myocardial infarction (AMI) among chest pain patients in the emergency department (ED). But usually, they included many variables or high-sensitive cardiac biomarkers which make them less optimal for generalization. We developed 3-level (prehospital, ED triage, ED doctor’s initial exam) prediction model that could be used in many emergency medical systems.

Methods

Multivariable logistic regression model (LR) and gradient boosting model (GBM) were developed on data from 8,673 ED visit for chest pain. Only variables which would be available shortly after patient presentation were used. 3-level modeling have been done and variables obtained in each level were chosen. Electrocardiogram (ECG) and high-sensitive cardiac biomarker were excluded for their fundamental diagnostic value. We evaluated performance by area under receiver operating characteristic curve (AUROC). Developed models were validated on validation data of 1,767 ED visit.

Results

About 8,673 subjects, patients diagnosed as AMI in ED were 866. AMI patients more likely to be older male, show higher triage severity, use emergency medical service and present typical chest pain. Variables chosen for 3-level were as follows: age, sex, time from symptom onset, mental status, ambulance use in prehospital level, triage result, shock state, tachycardia or bradycardia in ED triage level and atypical presentation of chest pain, hemoglobin, glutamic oxaloacetic transaminase (AST), glutamic-pyruvic transaminase (ALT), abnormal chest radiograph result for ED doctor’s initial exam level. We calculated AUROC of LR/GBM model: 0.697/0.703 in prehospital, 0.731/0.732 in ED triage and 0.773/0.787 in ED doctor’s initial exam level.

In validation data of 1,767 patients, AMI patients were 222. We applied same prediction model developed in test data and AUROC were as follows: 0.695/0.704 in prehospital, 0.724/0.725 in ED triage and 0.784/0.788 in ED doctor’s initial exam level.

Discussion & Conclusions
We developed multi-level prediction model of AMI for chest pain patient who visit ED. GBM models showed slightly better performance in both data.

Kihong KIM (Seoul, KOREA), Jeong Ho PARK, Young Sun RHO
14:50 - 14:55 #18971 - SP004 Treatment used in atrial fibrillation in patients with or without previous diagnosis of atrial fibrillation.
SP004 Treatment used in atrial fibrillation in patients with or without previous diagnosis of atrial fibrillation.

Introduction. Atrial fibrillation (AF) is the most frequently found sustained arrhythmia in the emergency department. The presence of AF complicates the management of patients presenting as medical emergencies. The treatment is focused on the control of the frequency and cardiac rhythm. AF is associated with an important morbimortality in the form of stroke, thromboembolism and heart failure.

Objective. The aim of the present study is to evaluate the drugs used in treatment of atrial fibrillation in patients with and without prior atrial fibrillation in the emergency department.

Methods. A descriptive observational, and retrospective study in a Hospital Comarcal Del Noroeste Murcia (a rural Centre of Spain) is described. In this study were included all patients aged 18 years with atrial fibrillation as diagnosis in emergency room from the 1st January to the 31th December 2017. We analyzed the pharmacological treatment.

Results. The sample under study is constituted by 209 patients: 116 with previous diagnosis of AF and 93 no. The patients with previous diagnosis of AF had average heart rate 103.27 bpm and the patients without previous AF had average heart rate 101.31 bpm. The treatment used in the emergency department in the patients with previous diagnosis of AF was: electrical cardioversion in 4.3% (5 patients), bisoprolol in 19.83% (23 patients), amiodarone in 20.69% (24 patients), digoxin in 16.38% (19 patients), flecainide in 8.62% (10 patients), diltiazem in 3.44% (4 patients), and other antiarrhythmics in 8.62% (10 patients). The treatment used in the emergency department in the patients without previous diagnosis of AF was: electrical cardioversion in 8.61% (8 patients), bisoprolol in 13.98% (13 patients), amiodarone in 11.84% (11 patients), digoxin in 16.13% (15 patients), flecainide in 4.3% (4 patients), diltiazem in 7.53% (7 patients), and other antiarrhythmics in 12.9% (12 patients). About the patients with previously AF, 54.68% had a sinus rhythm at discharge, and 45.32% remained in AF. Regarding patients without previous diagnosis of AF, 66% had a sinus rhythm at discharge, and 34% remained in AF. The mean time of staying at the emergency room was 508.14 minutes in patients with previously AF and 510.63 minutes in patients without previously AF.

Conclusion. We detected differences in the treatment between patients with de novo AF and previously diagnosis AF but the mean time staying in emergency room was similar in both groups. There is a greater tendency to perform electrical cardioversion in patients without previous AF. About the drugs, greater use was of Bisoprolol, Amiodarone and Digoxin in both groups. Bisoprolol is used in a lesser proportion in patients with previously AF, with greater use of Amiodarone. Sinus rhythm control was obtained in greater proportion in patients without previous diagnosis of AF. The mean time of staying at the emergency room was similar in both groups.

Nuria VICENTE GILABERT, Francisco Manuel RODRÍGUEZ RUBIO, Raquel CANTÓN CORTÉS, Carlos Máximo JAIME MORENO (Barcelona, SPAIN), Marta VICENTE GILABERT, Marta CAÑADILLA FERREIRA, Jorge ESCRIBANO POVEDA

Sunday 13 October

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EPOSTER 1.2
14:35 - 14:55

ePoster 1.2 - Short Oral Presentation - Screen 2

14:35 - 14:55 #18338 - SP005 The “Stroke Code” model in a low-resources first-level Emergency Department.
SP005 The “Stroke Code” model in a low-resources first-level Emergency Department.

Background: Systemic thrombolysis (STL) protocols are currently used in stroke centres around the world to reduce the treatment delay. These models were designed and most applied in tertiary hospitals with wide availability of neurology physicians and a dedicated stroke team. We brought  the American Heart Association/American Stroke Association (AHA/ASA) “Target: Stroke” initiative guidelines in a first-level Emergency Department (ED), where acute stroke patients are entirely managed by Emergency Physicians (EPs) with only radiology specialists consultants.

 

Methods: In 2018 a “Stroke Code” model was implemented in the ED of the Santa Maria Nuova first-level Hospital in Florence, including key components of the Helsinki model such as EP, radiologyst and laboratory technicians allert since ambulance transport, rapid Triage protocol, rapid EP evaluation, creation of a “stroke bag” with every stroke tool in use, early tissue plasminogen activator (Alteplase, tPA) preparation and infusion in the contrast tomography (CT) area, and prompt data feedback. A phone-alert protocol was established with our Territoral Emergency Service (TES): the EP of the TES operative base remotely identify the stroke codes from the ambulance team information and alert the ED. ER nurse apply a dedicate Triage protocol, characerized by the fast confirmation of ongoing deficit and acute (<4.5h) onset and immediate transfert in the emergency room (ER). EPs collect essential anamnestic and clinical data to identify indications and controindications to STL, while the ER nurses obtain at least one large-bore peripheric venous access, blood test samples  and check vital parameters before going to the CT-area. After the non contrast head CT-scan the radiology consultant give immediately a temporary answer reporting only the presence or absence of intracranial bleedings and/or radiologic STL contraindications, in order to allow the EP to start STL. After tPA bolus the patients undergo a contrast CT-scan. The 1-hour tPA infusion is beginned back in the ER. When a large-vessel obstruction is detected, a neuroradiological consultation is performed, and if indicated the patient is trasfered to local stroke hub centre for local treatment. Everyone involved in the stroke-code pathway had a specific 2-hour theorical training, implemented with one high-fidelity in-site simulation. Door-to-needle time (DTN) is registered, and all stroke patients data are collected in a dedicated registry to identify and correct specific delays and monitor activity.

Results: Before the stroke-model application the DTN [mean±standard deviation, (interquartile range)] was 76±33 (56-99) minutes. In the first year of stroke code model implementation the DTN was significantly lower 38±26 (20-50) minutes, p<0.001. Patient who received STL were more likely to experience a complete neurological recovery (59% treated vs 41% non-treated, p=0.002). Three (6%) patient had haemorragic complications, all of them had an acute stroke final diagnosis, and no one had permanent sequaele (mRs 0, 0 and 1, respectively).

Conclusion: The stroke-code model can be successfully applied after a brief training period  in a low-resources first-level ED in order to reduce DTN for acute ischaemic stroke treatment. In our experience the stroke-model performing was associated with a better functional outcome without any clinically relevant harm.

Simone BIANCHI, Francesco PROSPERI IOVI (Firenze, ITALY), Alessandra GIUELLO, Gabriele BANDINELLI, Federico LISI, Chiara ALAMANNI, Michele LANIGRA, Rita MARINO, Angela KONZE, Roberto CARPI, Vieri VANNUCCHI, Fererico MORONI, Giancarlo LANDINI
14:35 - 14:55 #18341 - SP006 Is LP useful in suspected SAH?
SP006 Is LP useful in suspected SAH?

Utility of lumbar puncture (LP) after a normal brain computed tomography (CT) scan in patients presenting to the emergency department with suspected Subarachnoid Haemorrhage: a retrospective cohort study

Background:


The diagnostic approach for patients presenting to EDs with severe, sudden-onset headache suspected for SAH remains challenging. 

Modern third generation computed tomography is shown to be extremely

sensitive in identifying subarachnoid haemorrhage when it is carried out

within six hours of headache onset and interpreted by a qualified radiologist, therefore may eliminate the need for lumbar puncture. However, some clinicians still perform LP even after a normal CTB even within this time frame, which is an invasive, time consuming procedures with known complications (i.e. post LP headache, Infection and bleeding at the site, Transient or permanent Neurological complications etc). 

 

 



Objective: To assess the utility of LP in emergency patients being evaluated for

possible subarachnoid haemorrhage after a negative non-contrast brain CT scan

 

 

Method:
We conducted a retrospective data analysis in three emergency departments in Monash Health in Victoria, Australia, focussing on patients presenting with concerning headache and being evaluated for possible subarachnoid haemorrhage between June 2013 and June 2018. Patients were excluded if they had a history of recurrent headaches or were discharged without further investigations. A diagnosis of Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography.

 

Results: 
Of 5746 enrolled eligible cases, 2039 (35.5%) were further investigated with a CT brain based on history and examination. 397 patients (19.5%) were diagnosed with SAH after CT, while 1642 (80.5%) had a negative CT scan. Of this remaining cohort, 388 (23.5%) patients underwent LP, and neither of them demonstrated a true positive SAH.

 
The 1254 patients with a negative CT scan whom did not undergo a lumbar puncture were followed up for 6 months by hospital and community record review. In this cohort of patients, 401 cases were lost to follow-up owing to a lack of available data. Of those followed-up, 1 patient died from haemorrhage stroke during his third hospitalisation.

 

Conclusion:

 

LP is not required in all patients with suspected subarachnoid haemorrhage with a negative CT scan and it should be decided on a case by case basis. Further analysis is to determine if there are defining characteristics that eliminate the need for LP which can result in unnecessary risks and complications, with minimal benefit in diagnosing SAH.

 

Pourya POURYAHYA (Melbourne, AUSTRALIA), Alastair MEYER, Easaw-Mamutil NAOMI , Yan TAN , Hui (Glen) TENG
14:35 - 14:55 #18911 - SP007 A retrospective cohort study analyzing whether the ottawa ankle rules are correctly applied in the emergency department of a university hospital.
SP007 A retrospective cohort study analyzing whether the ottawa ankle rules are correctly applied in the emergency department of a university hospital.

ABSTRACT

Purpose

The Ottawa Ankle Rules (OAR) were developed in 1992 in order to develop decision rules for the use of radiography in the emergency department (ED) and reduce unnecessary imaging. The purpose of this study is to evaluate how these OAR were applied in the ED of a university hospital between the 1st of July and the end of December of the year 2016. It examines how the OAR application in the ED has evolved compared to a similar study with data from 2015. The previous study led to changes in protocol as well as the implementation of training to improve the application of the OAR in triage. This study evaluates the success of these changes and trainings as well as whether predictive factors can be identified that drive the application of the OAR in the ED.

Method

In a retrospective cohort study, a sample of patient records aged between 6 and 98 years old with ankle trauma were analyzed, using descriptive statistics, for the application of the OAR at triage and for use of imaging. Logistic regression was used to identify predictive factors.

Results

The OAR were applied at triage in 90% of the cases. This is up from the 60% established by a previous, similar study a year before. However, imaging was still taken in 60% of cases where the OAR were negative. The study could identify some statistically significant predictive factors, but their predictive power is low as they explain 10% of the variation in the data of the OAR application.

Conclusion

The application of the OAR at triage has achieved a high level in this university hospital. The progress from 60% in 2015 to 90% now can be attributed to the training of medical staff in OAR application. The high percentage of imaging taken in OAR negative cases remains an area for further research to identify root causes.

Pauline SCHAUMANS (Jette, BELGIUM), Carol CLINCKAERT, Ives HUBLOUE
14:35 - 14:55 #18954 - SP008 Screening for pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.
SP008 Screening for pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.

Introduction Chest pain is a common chief complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism (PE) remains a key concern for the clinician. There are no clear recommendations on which patients should undergo a formal work-up for PE diagnosis. The purpose of our study was to determine the percentage of chest pain patients who are investigated for PE diagnosis and to determine the clinical profile of these patients. 

Methods We performed a retrospective multicenter study in 3 French Emergency Departments. We included all patients who visited these centers for a chest pain during a two month period. Patients were excluded if they were already treated for, or diagnosed with a thrombo-embolic event at the time of ED presentation. The primary outcome was the initiation of PE workup. This was defined by any evidence or mention in the chart of this diagnosis and reason for its rule-out or confirmation, namely order of D-dimers, CTPA, V/Q scan or lower limbs venous Doppler ultrasound. We also aimed to find factors associated to this outcome. 

Results We included 881 patients with a chief complaint of chest pain. Mean age was 49 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27% to 33%) underwent a formal PE workup, 235 (89%) of them had a D-dimer testing and 50 underwent a CTPA. Four patients had a lower limb venous doppler, and PE was explicitly ruled out on the basis of a PERC score of zero in 22 (8%) patients. PE was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1% to 5.3%). In the multivariate logistic regression model, five factors were identified as independently associated with a workup for PE diagnosis: female gender, young age, no ischemic heart disease, recent flight, and associated dyspnea. 

Conclusion Among patients visiting the emergency department with a chest pain, 30% underwent work up for PE. We report five clinical variables independently associated with a higher probability of PE workup in our sample.

Antoine LEFEVRE-SCELLES, Melanie ROUSSEL (Rouen), Paul JEANMAIRE, Anne-Laure PHILIPPON, Luc-Marie JOLY, Yonathan FREUND

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EPOSTER 1.3
14:35 - 14:55

ePoster 1.3 - Short Oral Presentation - Screen 3

14:35 - 14:40 #18297 - SP009 Comparing of CPR related trauma: mechanical chest devices vs. manual CPR.
SP009 Comparing of CPR related trauma: mechanical chest devices vs. manual CPR.

Introduction:

Resuscitation (CPR) with mechanical chest devices are not recomanded for routine CPR according to randomised trials. One of possible explanation could be CPR related trauma caused with mechanical chest devices. Current data are based on subanalysis from randomised trial, but autopsies are limitated by law and autopsy results are not objectivised.

Aim:

To compare injuries after CPR in autopsy results by manual resuscitated and mechanical (LUCAS 2, AutoPulse, CORpulse) resucitated patients and establish possible proportion of CPR related injuries on death without respect to cause of cardiac arrest.

Methods:

Retrospective multicentric study based on autopsy reports by patients died after CPR, patients with traumatic cause of cardiac arrest were excluded. Patients were devided in two groups: mechanical and manual CPR. For objective evaluation of injury seriousness we used Abbreviated injury scale scoring for the most serious injury and New Injury Scale Score for summary of all injuries.

Results:

We have enroled 704 patients, after trauma exclusion we have analyzed 630 autopsies. Manual CPR were provided by 559 patients and mechanical by 64 patients. Both groups are no diferent in age, gender, bystander CPR anad cardiac etiology of Arrest. Mechanical CRP was significantly longer (p=0,0005). Both groups have no diferences in incidency of injuries of thoracic vessels, lungs, heart, pericard, pleura, stomach, liver and spleen. We have observed injuries by 80% of manual and 87,5% of mechanical CPR. The most frequent was thorax sceleton injury 85,5% vs. 87,5%. Median of the most seriuos injury was 3 ( serious by Abbreviated injury scale scoring) without statistical difference, median of summary of injuries (New Injury Severity Score) was 13 in both groups ( low probability of fatal injury). If we analysed CPR by LUCAS 2 compared to manual, results are similar, only pericard injuries are higher with LUCAS 2.

Conclusion:

Incidency a seriousness of CPR related injuries according to autopsy reports are no diferent in comapring of manual and mechanical CPR. Mechanical CPR is significant longer a LUCAS 2 leads to significant more pericard injuries without influence to total seriousness of injury.

Jiri KARASEK (Prague, CZECH REPUBLIC), Betka BLANKOVA, Andrea DOUBKOVA, Tereza PITASOVA, David NAHALKA, Tomas BARTES, Jiri HLADIK, Tomas ADAMEK
14:40 - 14:45 #18371 - SP010 Correlation between serum levels of lactate dehydrogenase and neurological outcomes in patients who undergo target temperature management after cardiac arrest.
SP010 Correlation between serum levels of lactate dehydrogenase and neurological outcomes in patients who undergo target temperature management after cardiac arrest.

Background: The optimal time to measure serum lactate dehydrogenase level (SLL) to predict prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the relationships between time-related SLL and neurological prognosis in CA survivors.

Methods: We conducted a retrospective study examining patients with CA who were treated with target temperature management (TTM). SLL was checked repeatedly at 24-h intervals after return of spontaneous circulation (ROSC). SLL at ROSC and 24-, 48-, and 72-h outcomes were the relationships between each time interval SLL and the neurological outcome 3 months post-CA.

Results: A total of 256 comatose patients with CA were treated with TTM. Seventy-three patients were included, and 31 patients (42%) experienced a good neurological outcome. At 24, 48, and 72 h, there was a significant difference between good and poor outcome groups (p<0.001), except at ROSC (p = 0.056). The area under the receiver operating curve (AUC) of at ROSC was 0.631 (95% confidence interval [CI], 0.502–0.761). The AUC at 48 h (0.830; 95% CI, 0.736 – 0.924) was higher than that at 24 and 72 h (0.786; 95% CI, 0.681–0.892 and 0.821; 95% CI, 0.724–0.919).

 Discussion & Conclusions: A higher SLL was strongly associated with and seemed predictive of poor outcomes. Furthermore, at 48 and 72 h, SLL may be a useful predictor of poor neurological outcomes. Prospective studies should be conducted to confirm these results.

Jin Hong MIN, Hoil KIM (Daejeon, KOREA)
14:45 - 14:50 #18574 - SP011 The prognostic value of pre-arrest neutrophil-to-lymphocyte ratio for in-hospital mortality in adult patients with in-hospital cardiac arrest.
SP011 The prognostic value of pre-arrest neutrophil-to-lymphocyte ratio for in-hospital mortality in adult patients with in-hospital cardiac arrest.

Background

  As an indicator of systemic inflammation, the neutrophil-to-lymphocyte ratio (NLR) has been proved to be associated with a prognosis of a range of inflammation-related diseases. Although the study found that post-arrest NLR can predict the poor outcomes in patients with in-hospital cardiac arrest (IHCA), the relationship between pre-NLR and worse prognostic of IHCA patients was unclear. This study aimed to investigate the association between pre-arrest NLR and in-hospital mortality in patients of IHCA. We hypothesized that pre-arrest NLR is related to in-hospital mortality of IHCA patients.

Methods

  This was a single-center retrospective cohort study recruited IHCA patients in the emergency department (ED) of West China hospital of Sichuan University between January 2016 and May 2017. This hospital is a 4300-bed tertiary teaching hospital and is one of the largest medical centers in the southwest of China. Consecutive patients with cardiac arrest in the ED were included in this study. We excluded patients younger than 18 years, major trauma, lack of necessary data for analysis and hematological diseases or receiving any treatment which might affect the pre-arrest NLR values. Patients were divided into two groups according to the outcomes of in-hospital mortality. Clinical information and blood sample results were collected. Multivariate regression models were used to evaluate the associations between pre-arrest NLR and in-hospital mortality. The receiver operating characteristic (ROC) curve was used to assess the predictive value of pre-NLR.

Results

  Out of 488 IHCA patients during the study period a total of 385 (78.89%) patients were eligible for analysis, of those 267(69.35%) were male and mean age was 60.63±17.27. Of 385 patients, 64 (16.62%) survived to discharge. Patients with in-hospital mortality had a significantly higher pre-arrest NLR compared with survival to discharge patients (11.32[6.98,17.68] vs. 3.65[3.16,6.01], p<0.001). In the univariate model, pre-arrest NLR was associated with in-hospital mortality (OR: 1.347, 95% CI: 1.222-1.484, p<0.001). In the multivariate adjustment, higher pre-arrest NLR was independently associated with in-hospital mortality (AOR=1.276, 95%CI:1.160-1.403, p<0.001) after adjusting for age, gender, history of renal insufficiency, total CPR duration, globulin, alanine transaminase and aspartate aminotransferase.Furthermore, the prognostic performance of pre-arrest NLR was excellent (AUC: 0.86 [95%CI: 0.80-0.92, p<0.001]).

Discussion 

  In this retrospective observational study, we found that the excellent predictive ability of pre-NLR to predict in-hospital mortality for patients resuscitated from IHCA. We demonstrated the pre-arrest NLR is also a predictor for in-hospital mortality in IHCA patients. Therefore, we have reason to speculate that the systemic inflammatory response and the potential immune dysfunction before resuscitation in critically ill patients are associated with poor prognosis after resuscitation. Timely and effective medical interventions for critically ill patients might improve the survival when IHCA occurs.

Conclusions

  Pre-arrest NLR is a useful predictor of in-hospital mortality in adults with IHCA.  

Ethical approval and informed consent

   The study was conducted in line with the Declaration of Helsinki and gained approval by the Ethical Committee of West China Hospital of Sichuan University(Reference number: 2019201).

Sheng YE (ChengDu, CHINA), Junzhao LIU, Yarong HE, Yu CAO
14:50 - 14:55 #18776 - SP012 EVALUATION OF CARDIOPULMONARY RESUCITATION (CPR) TRAINING IN HEALTH CENTRE STAFF.
SP012 EVALUATION OF CARDIOPULMONARY RESUCITATION (CPR) TRAINING IN HEALTH CENTRE STAFF.


Introduction

Knowledge of Basic Life Support (BLS) techniques generates an undisputed benefit by improving survival prognosis in any CPR case, provided that BLS measures are initiated within the first 4 minutes of the CPR, and the comprehensive emergency system included within the "Chain of Survival" is implemented. International experience has shown that learning the instrumental management of the airway by the "first responders" is useful for increasing survival rates. For early defibrillation to be possible, knowledge about the use of semi-automatic defibrillation needs to be widely disseminated among staff in different health units.

Objectives

To know the degree of knowledge in Cardiopulmonary Resuscitation (CPR) among the health personnel of 10 urban and rural health centers prior to the realization of a plan of fromación in the form of workshops of eminently practical content.

Method

Prior to the workshop, 120 surveys were distributed among the participants consisting of 20 questions with 2 or 3 answers in Likert format referring to demographic data (profession, age and sex) and different aspects of basic resuscitation techniques with instrumental support and drugs. The surveys were analyzed with the SPSS version 20 database.

Results

The response rate was 100%. The degree of knowledge of the different techniques is shown in the tables provided, although in general terms, a knowledge deficit is detected in all the techniques analysed, which increases as the complexity of these techniques increases. This is despite the fact that 94.9% of the professionals admit to having received a course in CPR and 89.8% are aware of the ABCDE alert system.

Conclusions

The level of knowledge in cardiopulmonary resuscitation techniques demonstrated in this study by health professionals working in Primary Care is scarce, which makes it very necessary for health authorities to implement training programmes if we want to improve the response of these professionals to cardiac arrests in the hospital setting.

Álvaro MARTÍN PÉREZ (BADAJOZ, SPAIN), Rosario PEINADO CLEMENS, Concepción DE VERA GUILLEN, Juan M FERNÁNDEZ NÚÑEZ, Milagros LUCAS GUTIERREZ

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EPOSTER 1.4
14:35 - 14:55

ePoster 1.4 - Short Oral Presentation - Screen 4

14:35 - 14:40 #18200 - SP013 Salivary biomarkers role in pain diagnostics.
SP013 Salivary biomarkers role in pain diagnostics.

Introduction

The key to adequate pain management is assessing its presence and identifying exact severity of the pain. Current ‘gold-standard’ pain assessment tools rely on self-reporting, requiring an ability to communicate this personal experience. Self-reporting varies from patient to patient and could be inaccurately understood by healthcare professionals. According to the study results, acute as well as chronic pain remains one of the most misunderstood, under-diagnosed, and under-treated medical problems, particularly in children. Pain diagnosis and management would benefit from the development of objective markers of nociception and pain.

Aims

To investigate concentration of salivary cortisol and melatonin in children with acute pain and compare it with severity of pain and changes in vital signs.

Methods

We conducted a pilot observational study in Lithuanian University of Health Sciences Hospital Kauno Klinikos Pediatric emergency department (PED). Twenty six patients complaining of acute pain referred to PED were included into the study. Patients having chronical conditions (cancer, immunodeficiency, diabetes etc.), fever, dehydration or chronic pain were excluded. We recorded patient’s gender, age, vital signs (heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (t°) and oxygen saturation (SaO2)), pain characteristics (severity and duration of pain according the used pain scale and its localization). Saliva samples were collected and were stored in -80°C till analysis was performed. Samples were analyzed using cortisol and melatonin ELISA kits.

Results

Sixteen boys and 10 girls were involved in our research. Age median was10 (4-16) years. Fourteen cases were trauma patients, 12 cases referred due to pain of other origin then trauma. Analyzing vital signs, we noticed HR and BP increase with regard to pain. Other parameters (RR, t°, SaO2) were within the age range. The median of cortisol and melatonin levels were 287.5 (68-1330) pg/ml and 17,6 (8,6-46,8) pg/ml respectively. There were several findings related to saliva hormone level and intensity of pain, duration of pain and it’s link to vital signs There was a tendency to melatonin reduction with increased intensity of pain (p=0,136). The longer the pain lasted, the higher cortisol levels were identified (p=0.01). However, there was no link between abnormal vital signs and changes in our biomarkers.

Conclusion

Our primary results show a cortisol rise with regard to pain in time dependent manner. Melatonin levels decreased in relation to increased pain intensity. These results show a potential of cortisol and melatonin as biomarkers in acute pain diagnostics. 

Kristina GANZIJEVA (Kaunas, Lithuania, LITHUANIA), Lina JANKAUSKAITE
14:40 - 14:45 #18203 - SP014 The efficacy of platelet to lymphocyte ratio to predict mortality with gastrointestinal perforation patients.
SP014 The efficacy of platelet to lymphocyte ratio to predict mortality with gastrointestinal perforation patients.

Objective:  The platelet to lymphocyte ratio (PLR) is a recognized marker of inflammation associated with poor outcomes in various clinical situations. Gastrointestinal perforation (GIP) is a life-threatening disease with a high mortality rate. We analyzed the prognostic significance of PLR in patients with gastrointestinal perforation (GIP) undergoing surgery.

 

Method : This was a Single-center observational retrospective study. A total of 245 patients with gastrointestinal perforation (GIP; esophageal, small bowel, colon, rectal perforation) undergoing surgery in a Korean hospital between January 2009 and December 2018 was enrolled. The primary outcome was all-cause in-hospital mortality. Multivariate logistic regression was used to determine the predictive value of PLR on in-hospital mortality.

 

Results: Of total 245 patients, 25(10.2%) died and 220(89.8%) survived. In the Multivariate logistic regression analysis, factors associated with in-hospital mortality were Respiratory rate (RR), CRP, HCO3 and PLR (odds ratio = 1.53[95% confidence interval, 1.04-2.27], 1.01[1.01-1.02], 0.83[0.71-0.97], 0.95[0.91-0.99], respectively).

 

Conclusion: We demonstrated that a lower PLR predicted worse survival in patients with gastrointestinal perforation undergoing surgery. The PLR may help to identify high-risk patients in time.

Yeonghoon BAE (Seoul, KOREA)
14:45 - 14:50 #19059 - SP015 Utility of s-tryptase in Emergency Department patients with possible anaphylaxis.
SP015 Utility of s-tryptase in Emergency Department patients with possible anaphylaxis.

Background: Diagnosing anaphylaxis is straight forward in typical cases but can be challenging if the presentation is atypical. Generally it requires that patients have acute symptoms from more than one of the following systems; skin or mucosa, respiratory, cardiovascular or gastrointestinal. In addition to clinical diagnosis it has been shown that in patients with vague or atypical symptoms considered possibly due to an acute allergic reaction, evaluating s-tryptase can give additional diagnostic information, ideally if done within 30-180 min from onset of symptoms. Measuring s-tryptase also has the potential to diagnose mastocytosis, a rare but probably underdiagnosed condition of mast cell proliferation.

In our emergency department (ED), staff has been educated since 2011 on obtaining a s-tryptase level in cases where a patient could possibly be having an acute allergic reaction but a definitive diagnosis cannot be made based on clinical evaluation. Further evaluation by an allergist during an outpatient follow up is also recommended. The aim of this study was to assess how useful obtaining a s-tryptase level was on the work up of patients with possible anaphylaxis in the ED.

Methods: With institutional review board approval, all cases where a s-tryptase level was obtained from ED patients during the period from 2011-2018 were retrospectively reviewed. A database was collected including information on patient demographics, presenting symptoms and signs, treatment given, diagnosis, s-tryptase level and follow up.

Results: During the study period a total of 214 patients in the ED had s-tryptase measured. Females were 131 (61.2%) and average age 40.6 years (range 11-88). When evaluating patients, 60 (28.0%) of patients had only symptoms from one organ system, 70(32.7%) from two, 55(25.7%) from three and 26(12.1%) of the patients had symptoms from four organ systems. Three patients (1.4%) did not have symptoms from any of the four target organ systems.  Of the patients, 86.4% had skin or mucosal symptoms, 47.7% cardiovascular symptoms, 49.5% respiratory symptoms and 36.0% had gastrointestinal symptoms. Blood was drawn for s-tryptase analaysis within the recommended time frame in 133(62.1%) of the cases. Serum tryptase was elevated (>12µg/l) in 36 (16.8%) cases.

Of the 214 cases, 126 returned for further evaluation by an allergist and 65 (51.6%) of those were considered to have had an episode of anaphylaxis.

When evaluating the cases where blood samples for s-tryptase analysis had been collected within the recommended time frame of 30-180 minutes and returned for further evaluation by an allergist, the sensitivity of s-tryptase to diagnose anaphylaxis was 40,91% (95% CI 26,34% - 56,75%) and specificity 96,30% (95% CI 81,03% - 99,91%). No case of mastocytosis was identified in the patient cohort.

Discussion and conclusions: Obtaining a s-tryptase level on ED patients with possible anaphylaxis is specific but not sensitive in diagnosing atypical cases of anaphylaxis. No cases of mastocytosis were identified in the patient cohort suggesting that mastocytosis is uncommon among ED patients in our community.

Karolina HANSEN, Hjalti Mar BJORNSSON (Reykjavik, ICELAND), Maria I GUNNBJORNSDOTTIR
14:50 - 14:55 #19219 - SP016 High cortisol levels predict worse outcome in patients with community pneumonia.
SP016 High cortisol levels predict worse outcome in patients with community pneumonia.

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) is a condition still not completely understood. Although the current guidelines suggest the administration of corticosteroids only in septic patients who do not respond to the initial fluid resuscitation, it is not clear how it works and the signaling pathways that may affect its efficacy.

Therefore, we made the hypothesis that corticosteroids therapeutic action may be related not only to cortisol levels, but also to the degree of glucocorticoids receptors (GR) expression.

We included in this study 181 patients presented to the Emergency Room with the diagnosis of community pneumonia. Blood samples were collected at the admission and outcomes were evaluated during hospital stay and after 30 days.

Cytokines were measured by Multiplex method, and glucocorticoid receptors α and β were measured in leukocytes homogenates by ELISA. Data are presented here as mean±SEM. 

Patients’ ages vary from 18.2 to 100.0 y.o (average = 61.7±1.5). From the 181 patients, 96 were also septic and 40 had septic shock. Mortality was 17.7% (32 patients). Seventeen of these patients were chronic corticoid users and were evaluated separately. 

The main discriminators between survivors and non survivors were SOFA (2.9±0.2 vs 4.8±0.4, respectively, p<0.05) and total cortisol levels (18.5±2.1 vs 39.7±8.2, respectively, p<0.05). There was no difference in GR α or β expression between survivors and non survivors. Previous corticosteroid use also did not affect the levels of GRs expression, suggesting that these receptors are not subjected to feedback regulation.

In addition none of the inflammatory markers measured at admission (proadrenomedulin, procalcitonin, C-reactive protein or cytokines) were able to distinguish the patients who would survive.  

In conclusion, we showed that cortisol levels are a good predictor of outcome in patients with community pneumonia and GR expression did not affect this outcome. 

Lucas MARINO (Sao Paulo, BRAZIL), Hermes BARBEIRO, Denise BARBEIRO, Luzmarina GOMEZ, Julio ALENCAR, Julio MARCHINI, Rodrigo BRANDAO, Heraldo SOUZA

Sunday 13 October

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EPOSTER 1.5
14:35 - 14:55

ePoster 1.5 - Short Oral Presentation - Screen 5

14:35 - 14:40 #18284 - SP017 Temporal evolution of the PCVCO2-PaCO2 / CaO2-CcvO2 ratio versus serum lactate during resuscitation in septic patients with hypotension.
SP017 Temporal evolution of the PCVCO2-PaCO2 / CaO2-CcvO2 ratio versus serum lactate during resuscitation in septic patients with hypotension.

Bakground: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO2-PaCO2 / CaO2-CcvO2 ratio may be used as an alternative for the same.The primary objective of the study was to evaluate the correlation between serum lactate and PcvCO2-PaCO2 / CaO2-CcvO2 ratio measured at various time points to a maximum of 24h in patients with septic shock (Mean arterial pressure < 65mmHg). The secondary objectives were to study the  1) Relationship between the PcvCO2-PaCO2 / CaO2-CcvO2 ratio and lactate clearance at 6, 12 and 24 hrs as compared to the initial serum lactate. 2) To study the correlation between the arterial lactate and the PcvCO2-PaCO2 gap at each measurement. 3) Outcome in terms of ICU length of stay, organ dysfunction and mortality at day 28.

Methods: This prospective observational cohort study was conducted at the mixed ICU(Medical/Surgical)   of the All India Institute of Medical Sciences (AIIMS), New Delhi from July,2016 to April,2018.Thirty patients with sepsis-induced hypotension (MAP < 65mmHg) who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilisation of MAP (maximum of two samples), and 6 hourly thereafter for the first 24h. Patients were followed up to day 28 of enrolment for mortality and organ system failure. All statistical analysis was performed using ‘Stata’ software (Ver 15.1; StataCorp LLC, Texas, USA). Correlation between the various variables was done using the Spearman coefficient. Subgroup analysis of variables between survivors and non-survival groups was done using the Wilcoxon-Mann-Whitney test. Sensitivity and specificity of the PcvCO2-PaCO2)/(CaO2-CcvO2) ratio and arterial lactate were calculated and Receiver-Operating-Characteristic curves were constructed.

Results: A positive correlation was observed between arterial lactate and  PcvCO2-PaCO2 / CaO2-CcvO2 ratio at 0h, 6h, 12h, 18h (R=0.413 P=0.02; R=0.567 P=0.001; R=0.408 P=0.025; R=0.521 P=0.003, respectively). No correlation was seen between  PcvCO2-PaCO2 / CaO2-CcvO2 ratio and  lactate clearance. The subgroup analysis showed that neither an abnormal arterial lactate (> 2mmol/L) nor an abnormal PcvCO2-PaCO2 / CaO2-CcvO2 ratio (>1) at the time of enrolment could distinguish survivors from non-survivors (at D28 of enrolment). The median (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio was higher in non-survivors than in survivors at all time points. However, this reached statistical significance only at the 24h time point9 P=0.004). A PcvCO2-PaCO2 / CaO2-CcvO2 ratio>1.696 at 24h of resuscitation predicted mortality at 28d (Sensitivity: 80%, Specificity 69.2%, AU-ROC 0.82). This threshold also distinguished survival at D28 in the Kaplan Meier estimates (Chi-square=6.00, P=0.014). An arterial lactate > 1.6mmol/L at 24h of resuscitation predicted mortality at 28d (Sensitivity 73.33%, Specificity 69.23%, AU-ROC 0.853). This threshold also distinguished survival at D28 in the Kaplan Meier estimates (Chi-square=5.62, P=0.018)

Discussion and Conclusion(s): The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio and the lactate are positively correlated during the first 24h following active resuscitation from sepsis-induced hypotension. The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio at 24h is significantly higher in non-survivors, and a threshold of 1.696 mmHg/mL/dL for (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio at 24h significantly differentiates survivors from non-survivors. The (PcvCO2-PaCO2)/(CaCO2-CcvO2) ratio may be used as an end-point of haemodynamic resuscitation from septic shock.

Vimi REWARI (New Delhi, INDIA), Shyam MADABHUSHI, Anjan TRIKHA, Rahul Kumar ANAND, Rashmi RAMACHANDRAN
14:40 - 14:45 #18475 - SP018 P25/30 somatosensory evoked potential is superior to N20 in predicting neurological recovery after cardiac arrest: A prospective, observational study.
SP018 P25/30 somatosensory evoked potential is superior to N20 in predicting neurological recovery after cardiac arrest: A prospective, observational study.

Background

The absence of N20 somatosensory evoked potential (SEP) is regarded as a predictor of poor outcome after cardiac arrest with very high specificity. However, its sensitivity in predicting the poor outcome is unsatisfactory. The P25/30 SEP is a positive deflection following N20 with a latency of 25-35 msec. According to our prior study, N20 without following P25/30 is related to poor outcome, while N20 followed by P25/30 is highly related to good outcome. In this study, we evaluated whether the amplitude of P25/30 predicts neurologic recovery after cardiac arrest more accurately than the amplitude of N20.

Methods

This is a prospective multicenter observational study. Patients were consecutively enrolled in four university-affiliated teaching hospitals. SEPs of comatose survivors after out-of-hospital cardiac arrest treated by 33℃-targeted temperature management were recorded 72 hours after return of spontaneous circulation. The cutoff value of P25/30 and N20 amplitude showing 100% specificity in predicting poor neurological recovery was determined by receiver operating characteristic (ROC) analysis. We defined poor neurological recovery as the worst Cerebral Performance Category score higher than three during the admission period. We performed penalized maximum likelihood estimation in logistic regression analysis. Thereafter, we compared the area under curve (AUC) of the P25/30-based model predicting poor outcome to AUC of the N20-based model. According to the previous study, a total of 86 subjects would be required to detect a 0.05 difference in AUC with a power of 80% and a type I error of 5%. Values of p less than 0.05 were considered statistically significant.

Results

Out of a total of 87 patients included in the study, 43 patients showed good neurological recovery, while 44 patients showed poor neurological recovery. The cutoff values of SEP amplitudes showing 100% specificity in predicting poor neurological recovery were 0.63 μV (P25/30) and 0 μV (N20). Sensitivity in predicting poor neurological recovery of P25/30 was 0.86 (95% confidence interval 0.73 - 0.95), while N20 was 0.7 (95% confidence interval 0.55 - 0.83). In addition to N20 or P25/30, cardiac arrest rhythm and anoxic time were selected as independent variables for the multivariable logistic regression models. The AUC of the P25/30-based model was 0.958 (95% confidence interval 0.92 - 1), while the AUC of the N20-based model was 0.911 (95% confidence interval 0.85 - 0.98). AUC comparison between the N20-based model and the P25/30-based model showed a statistically significant difference (p = 0.02).

Conclusions

P25/30 showed superior value in predicting poor neurologic recovery after cardiac arrest than the N20. P25/30 showed higher sensitivity in predicting poor neurologic recovery than the N20, which implies potential as a predictor of good neurologic recovery.

Sang Hoon OH, Joo Suk OH (Seoul, KOREA), Hyunho JUNG, Jungtaek PARK, Ji Hoon KIM, Jeong Ho PARK, Jung Hee WEE, Seung Pill CHOI, Kyu Nam PARK
14:45 - 14:50 #18956 - SP019 Eligibility for organ donation: Is there a place in emergency department ?
SP019 Eligibility for organ donation: Is there a place in emergency department ?

Introduction: Actually, 60% of organ procurement is perfomed in patients who died of brain death due to a severe stroke, mainly haemorrhagic stroke (75%). The objective of this study is to identify patients in emergency departments for severe stroke who may be eligible for organ retrieval procedures. 

Methods: We realized an epidemiological, descriptive, observational, monocentric, retrospective study at a university hospital emergency department for one year including all strokes with a Glasgow coma scale ≤ 12 and/or a NIHSS score ≥ 17. We considered patients who died early (death < 3 days) and with no neoplasia as potentially eligible for organ donation and compared the characteristics of eligible patients to patients whose brain death has been confirmed.

Results: 1582 patients were hospitalized for stroke, 312 patients had a severe stroke. 201 patients, with severe stroke, was not managed in intensive care. In this cohort according to predefined criteria, 34 patients were considered eligible for multi-organ procurement. Fifteen (44%) had an ischemic stroke and 19 (56%) had a hemorrhagic stroke. The initial mean Glasgow coma scale was 6 (± 3). The median age was 84 years [77-89]. We compared patients with confirmed brain death (N=32) to potentially eligible donors (N=34). Age was significantly higher in potentially eligible patients (65 years vs 84 years; p < 0.0001). There was no significant difference in the Glasgow coma scale for antiaggregant or anticoagulant treatment between the 2 groups. 13 patients were cared for and died in neurology, 15 patients in the emergency department and 6 patients in short-term hospital units. Among potentially eligible patients, 75% of patients died within 48 hours. For patients with confirmed brain death, 75% of patients died within 72 hours. 

Conclusion: The identification of patients who may be eligible for organ retrieval is difficult in the emergency department. A better awareness of practitioners could make it possible to better filiarize the management of these patients.

Melanie ROUSSEL (Rouen), Antoine LEFEVRE-SCELLES, Edgar MENGUY, Mathieu BENHADDOUR, Luc-Marie JOLY
14:50 - 14:55 #19102 - SP020 Analysis of Single Substance Heroin Exposures reported to the U.S. Poison Centers from Healthcare Facilities.
SP020 Analysis of Single Substance Heroin Exposures reported to the U.S. Poison Centers from Healthcare Facilities.

Background: Heroin use has reached a public health crisis in the U.S. Since 2010, the rate for deaths involving heroin has almost tripled, from 1.5 per 100,000 in 2011 to 5.1 in 2016. The number of people using heroin for the first time in the U.S. has increased in recent years. Hence it is important to track heroin overdoses, especially those reported from the healthcare facilities (HCF) as these may greatly increase resource use. The objective of the current study is to use outline the epidemiology of single substance heroin exposures reported to the National Poison Data System from the HCFs.

Methods: The NPDS was queried for all human single substance exposures to heroin reported to the U.S. Poison Centers (PCs) from HCFs between 2011 and 2017. We descriptively assessed the relevant demographic and clinical characteristics. Trends in heroin frequencies and rates (per 100,000 human exposures from HCF) were analyzed using Poisson regression methods. Percent changes were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 15,692 single substance heroin exposures reported to the PCs from HCFs. The number of calls increased from 1,142 to 3,865 during the study period. Among these calls, 90.2% were reported from acute care hospitals and emergency departments (EDs), 6.5% were reported from freestanding EDs, while 3.3% were reported from physician offices.  Acute exposures to heroin were responsible for 67.7% of the calls from HCF. Approximately 19% of the patients reporting such heroin exposures were admitted to the critical care unit (CCU), with 56.6% patients treated and released. Residence was the most common site of exposure (69.7%). Among the patients, m were male, with the majority of the individuals between ages 20 and 39 years (70.9%). Pediatric cases accounted for 6.3% of the exposures. Intentional abuse (74.5%) and misuse (10.5%) were commonly observed reasons for exposure. During the study period, the proportion of heroin abuse cases increased (73.3% to 76.1%). Major effects were seen in 19.1% cases and the mortality rate for single substance heroin exposures from HCF was 1.8%. Notably, the number of heroin-related fatalities in this group doubled during the study period.  Coma (26.8%) and respiratory depression (27.3%) were frequently observed clinical effects. Naloxone (60.7%) was the most frequently reported therapy. During the study period, the frequency of heroin exposures increased by 238.4% (95% CI: 215.8%, 261.5%; p<0.001), and the rate of heroin exposures increased by 187.6% (95% CI: 149.8%, 231.2%; p<0.001).

Discussion: There was a significant increase in single substance heroin exposures reported to the PCs from HCFs during the study period. This increase may be a result of the lower cost of heroin and the tighter regulations on the prescribing of opioids. Changes in the sources of supply and potency of heroin products can result in substantial adverse events seen in the HCFs. Exposures reported to the poison centers further highlight the need for sustained, targeted, and multifactorial responses to the ongoing opioid epidemic, including timely surveillance.

Saumitra REGE (Charlottesville, VA, USA), Christopher HOLSTEGE
Monday 14 October
10:45

Monday 14 October

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EPOSTER 2.1
10:45 - 11:05

ePoster 2.1 - Short Oral Presentation - Screen 1

10:45 - 10:50 #18355 - SP021 Left holding the baby: reasons and outcomes of neonatal emergency department attendance, a 2-year retrospective observational study in a UK tertiary hospital.
SP021 Left holding the baby: reasons and outcomes of neonatal emergency department attendance, a 2-year retrospective observational study in a UK tertiary hospital.

Background and Objective

Neonates attending the paediatric emergency department (ED) pose challenges. The presenting problems differ from older children and are unique to this age group, prescribing requires attention to detail and consideration of physiological quirks and even resuscitation algorithms are irritatingly idiosyncratic. So who are these babies that are brought to the ED by their parents, what serious illness needs consideration and why are they attending the ED in the first place? We present a large data set with a view of identifying attendance patterns, population characteristics and potential pathway issues.

Methods

Retrospective review of all neonatal attendances (age less than 28 days) to the paediatric ED of a UK tertiary hospital during a two year period (01/04/2017 to 31/03/2019) from the electronic patient record database for age at presentation, presenting complaint, source of referral, length of stay in ED and disposal. Where necessary, individual records were accessed and any missing information added. Acuity of visits was determined by the need for admission, duration of in-patient stay and follow-up arrangements. 

Results 

1,699 attendances involving 1,467 neonates were identified, constituting 3.81% of all paediatric ED attendances (n=44,571) and 16.2% of all births in the hospital (n=10,515). The peak of attendance occurred at age 2-3 days, with over 60% presenting with jaundice. Monthly attendance mirrored the birth rate, there was no seasonal variation. The most common presenting problems were jaundice, respiratory symptoms, weight-loss and vomiting. Only 23.7% of all visits were self-referred. Most referrals came from midwifes (37.3%), other primary healthcare professionals (24.1%) and after contacting the UK’s 111 helpline (9.83%). 5.1% of babies came by emergency ambulance. As expected, the ratio of acute to non-acute visits was higher in referrals by ambulance (r=1.00) and primary healthcare professionals (r=0.808) compared to self-referrals (r=0.728) but not significantly so. On average, these infants spent 165 minutes in the ED. There were 111 breaches of the 4-hour target (6.42%). The admission rate was 42.1%, and the top reasons for hospital admissions were jaundice (44.3%), feeding problems (18.2%), respiratory (11.3%) and infection including suspected sepsis (7.97%). 32.9% of neonates admitted were discharged within 48 hours of admission. 4 deaths including two neonatal sepsis deaths were identified, both of which had disseminated Herpes-Simplex Virus (HSV) infection. 

Discussion

ED attendance is common during the neonatal period, notably over half of the visits are for non-acute complaints and do not require immediate medical intervention except parental reassurance.

The large number of jaundice-related attendances calls for a review of the jaundice care pathway. We will be discussing possible interventions that may help reduce unnecessary attendances in the ED like feeding support following postnatal discharge and improved awareness of neonatal normal variants by primary care professionals.

We suggest that the current referral algorithms for the UK's national telephone advice service 111 may significantly increase inappropriate ED attendances.

The neonatal deaths due to sepsis were both caused by HSV infection, our local incidence matching published evidence and we postulate Aciclovir to be first-line treatment in neonates presenting with sepsis to ED.

Yishen WANG (Cambridge, UK), Peter HEINZ
10:50 - 10:55 #18445 - SP022 Analysis of limited-sequence head computed tomography for children with ventriculo-peritoneal shunt: potential to reduce diagnostic radiation exposure.
SP022 Analysis of limited-sequence head computed tomography for children with ventriculo-peritoneal shunt: potential to reduce diagnostic radiation exposure.

Background and Objectives

Complications related to ventriculoperitoneal shunt (VPS) are common, and multiple revisions are almost expected throughout a patient's lifetime. Standard noncontrast head computed tomography (CT) that is currently the gold standard for diagnosis of VPS dysfunction, consists of an average of 35 to 40 sequences and causes severe radiation exposure. However, it is stated that the evaluation of four sequences which show 4 ventricles, 3 ventricles, lateral ventricles and basal ganglia may be sufficient for the diagnosis of VPS malfunction. This may significantly reduce the radiation exposure. The aim of this study was to determine the feasibility of the four-sequence limited head CT for predicting VPS malfunction.

Methods

We performed a retrospective analysis of the PED medical records (MRs) between January 2013 and December 2017 that involved all patients who received a head CT for suspected VPS malfunction. MRs were reviewed to describe demographic, clinical characteristics surgical interventions and full head CT reports. For all enrolled patients, a limited series was generated from the last CT scan by selecting four representative axial slices based on the sagittal scout image. Four slices selected at the level of the fourth, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded neuroradiologist evaluated the limited 4- slice CT to determine the VPS malfunction. After this review, we compared the standard full head CT reports with the limited 4- slice CT, and analyzed the sensitivity and specificity of the 4- slice CT to predict VPS malfunction. We also calculated the real 4 –slice CT sensitivity and specificity for children  who received surgical shunt revision.

Results

A total of 164 patients were enrolled in the study. The mean age was 54 ± 24 months and 85 (52%) were males. The most common presentation complaints were vomiting (27%) and seizure (17%). V-P shunt revision was performed in 60 patients (37%) as a result of clinical and radiological evaluation. When we compared the standard complete head CT reports with the limited modality, the limited 4-slice CT had sensitivity, specificity 83% and 97% respectively, for the evaluation of the changes in ventricular size. However, when the analyze performed based on surgical V-P shunt revision, only one case would have been missed with the limited 4-slice CT. The  sensitivity was 98% and specificity 78%. The effective dose (ED50) of limited 4-slice head CT was 0.32 mSv, while the ED50 of the standard head CT was 2.7 mSv. In this way, the prefer of a limited head CT instead of a complete head CT may provide about 88% reduction in radiation dose.

Conclusion

The present study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VPS malfunction is a feasible strategy for the evaluation of the ventricular size as well as prediction of surgical intervention. Further prospective, well designed studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VPS malfunction.

Ali YURTSEVEN (İzmir, TURKEY), Caner TURAN, Eren ERSEVEN, Cenk ERASLAN, Eylem Ulas SAZ
10:55 - 11:00 #18534 - SP023 Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.
SP023 Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort.

Background and Objectives: Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France.

Methods: We analyzed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital. Our database was approved by the French Data Protection Authority and by a French research ethics committee. Maternal consent was systematically requested before or during birth management (left at the physician’s discretion).

Results: From 2011 to 2018, 1,854 UOHB were recorded, of whom 520 were analyzed. We found that using incubator care was the most effective rewarming method (+0.8°C during transport; P < 0.001), followed by the combination of plastic bag, skin-to-skin and cap (+0.2°C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+0.0°C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator (Adjusted temperature difference = +0.33 95CI(0.13; 0.52)). According to the classification and regression tree (CART) method, we also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4°C).

Conclusions: Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature, using such a method would be preferred.

François JAVAUDIN (Nantes), Mélodie ROCHE, Lucile TRUTT, Isabelle BUNKER, Valérie HAMEL, Sybille GODDET, François TEMPLIER, Christine POTIRON, Quentin LE BASTARD, Philippe PES, Gilles BAGOU, Jean-Louis CHABERNAUD, Emmanuel MONTASSIER, Brice LECLERE
11:00 - 11:05 #19167 - SP024 Clinical decision rules in cervical spine injury assessment: a prospective study in a paediatric trauma centre.
SP024 Clinical decision rules in cervical spine injury assessment: a prospective study in a paediatric trauma centre.

Background:

Paediatric cervical spine injury (CSI) is rare but can have devastating consequences. In an attempt to identify all children with CSI, many children are assessed for possible injury and may either be “clinically cleared” or receive imaging to exclude radiologically apparent injury. Clinical decision rules (CDRs), or proposed rules, are commonly used to guide imaging decisions despite limited evidence for their use in paediatric populations.

 

Objectives:

To determine the frequency of previously identified risk factors for CSI in children presenting to a single Australian centre and to assess the performance of commonly used CDRs or proposed rules when strictly applied to our population, including the projected impact on imaging rates if these CDRs were strictly applied.

 

Method:

Prospective observational study across one year of all children under 16 years presenting to Emergency Department (ED) with possible CSI as defined either immobilization for possible CSI, neck pain the context of trauma or otherwise considered at risk by the ED team. Those with imaging prior to arrival were examined as separate cohort. CDR variables for the National Emergency X-ray Utilization Study (NEXUS) rule, Canadian Cervical Spine Rule and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.

 

Results:

1010 children were enrolled; 973 had not received prior imaging. Of these 973, two thirds were male, median age was 10.9 years and 16% were aged under 5. 40.7% received imaging of their cervical spine with 32.4% receiving X- Rays, 13.4% Computed Tomography and 3% Magnetic resonance imaging. 5 children had CSI.  Nine children of the 37 with prior imaging had CSI.

 All 3 CDRs identified the 5 children with CSI who had not received prior imaging (Sens 100%, 95%CI 56-100). The NEXUS rule did not identify 2 out of the 9 children with prior imaging. 

If strictly applied as a rule for imaging, all 3 CDRs or proposed CDRs would increase imaging rates in our setting, with individual CDR guided rates ranging between 44 and 68%. Despite these higher projected imaging rates, and while all but 2 imaged children were positive for at least one of the three rules (i.e. imaging indicated according to the CDR), no single rule suggested that all children  imaged in current practice should actually be imaged; individual NEXUS and PECARN CDRs were  positive in 82 and 91% of those imaged respectively.

 Conclusion:

Paediatric CSI is rare, and while many children are clinically cleared without imaging, a considerable percentage receive imaging for relatively few injuries detected. CDRs have been proposed to guide imaging decisions, however the use of those currently available to the paediatric practitioner, could, if strictly applied, result in more children receiving imaging than occurs in current practice. Research with a larger cohort is required to assess whether a more refined CDR can be designed to limit discomfort, cost and radiation exposure, and to formally determine the performance of current rules (including sensitivity in injury detection) in the paediatric setting.

 

Natalie PHILLIPS (Brisbane, AUSTRALIA), Katie RASMUSSEN, Sally GRAY, Kerrie Ann ABEL, Geoff ASKIN, Robyn BRADY, Mark WALSH, Jason ACWORTH, Franz BABL

Monday 14 October

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EPOSTER 2.2
10:45 - 11:05

ePoster 2.2 - Short Oral Presentation - Screen 2

10:45 - 10:50 #18014 - SP025 Effective Factors in Improving the Emergency Department Preparedness of Hospitals in Radiation and Nuclear Incidents and Nuclear Terrorism: A Systematic Review.
SP025 Effective Factors in Improving the Emergency Department Preparedness of Hospitals in Radiation and Nuclear Incidents and Nuclear Terrorism: A Systematic Review.

Background: Due to existence of nuclear power plant sites in various parts of the world, as well as political threats in disaster-prone areas throughout the world, there is a probability of nuclear and radiation incidents. The present study was carried out with the purpose to extract effective criteria in emergency department preparedness of hospitals in radiation, nuclear incidents and nuclear terrorism in different countries around the world.

Methods: A systematic search was carried out in Cochrane Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest and EmBase databases between January 1970 to July 2018. The systematic search was carried out according to the PRISMA standard. The required information was extracted from the papers based on the abstract and collection form.

Results: After searching the databases, 1091 papers were finally extracted. The initial search included research papers. After reviewing the papers’ titles, abstracts and full texts, 15 papers were selected for final analysis. Next, 32 criteria were extracted. The criteria were divided into 3 categories. The categories included staff, stuff and systems (structure). The most frequent criteria included training criteria, personal protective equipment, decontamination and practice.

Discussion and Conclusion: The results of the systematic review provided an overview of the effective factors in improving the emergency department preparedness during radiation and nuclear incidents. In addition to the mentioned criteria in different studies, there are other hidden factors that affect the emergency department preparedness in radiation and nuclear incidents, thus, the highest level of preparedness should be considered.

Ahmadi Marzaleh MILAD, Rezaee RITA, Rezaianzadeh ABBAS, Rakhshan MAHNAZ, Haddadi GHOLAMHASSAN, Peyravi MAHMOUDREZA (, IRAN, ISLAMIC REPUBLIC)
10:50 - 10:55 #18157 - SP026 Medical assistance coordination of terrorist attack.
SP026 Medical assistance coordination of terrorist attack.

Introduction: In case of mass casualty incident (MCI) abroad, medical assistance companies are entrusted to provide a rapid and appropriate response. In addition to a standardized and regularly updated operating process, exercises are key component to ensure performance. The purpose of the present report was to evaluate the effectiveness of our primary casualty plan on our different platforms around the world.

Methods and Setting: Our medical assistance company is present in 28 countries but only 5 large regional platforms are accredited to deal with MCIs. A primary casualty plan, common to all entities, governs all aspects of MCI management (activation, coordination, forwarded team on the spot, relation with Foreign Affairs, communication with media…) under the responsibility of the Group Medical Direction. The present simulation was a tabletop exercise (no field deployment). The scenario was a terrorist attack (fire arms, no bomb) in a touristic place in Senegal with 10 killed and 20 severely injured people from 6 different countries. Coordination of the exercise was performed by the Group Medical Direction with the help of an external team of facilitators located in the country of occurrence, following a detailed chronogram and giving inputs/responding to the different platforms involved. There were also observers on each platform. The exercise was kept secret toward platforms. The main evaluative criterion was the concordance between the response each platform provided and the primary casualty plan (considered as the standard). 

Results: Alert was sent to 6 platforms with victims involved at 8:00 GMT on Sept 19, 2018. After 60 min, 1 regional platform had implemented a specific desk with dedicated staff, activated the local medical correspondent, contacted the other platforms within its region and the other regional platforms, and been in touch with Foreign Affairs Ministry. This platform was designated as leading platform for the entire group. After 90 min, this leading platform had collected a brief description of injuries for all victims and initiated local evacuations for those who required urgent/invasive procedures. One of the doctors of the team was ready to fly over there for local coordination of repatriation, agents having flight options ready. Secrecy was disclosed at this point and exercise ended.

Discussion: This simulation clearly identified platforms in which our primary casualty planis mature and those that need further attention or training. Since most managers and head of platforms were not present at the time of the exercise, it was also interesting to challenge on how not to rely on them. Also the email server of the company was down that morning, which invited to further think on communication tools. Formal debriefing was conducted with heads of platform and chief medical officers 10 days after the exercise and improvement measures were discussed and decided. The program of simulation will be continued.

François-Xavier DUCHATEAU (Paris), Anne LEPETIT, Eic VANHALEWYN, Massemba DIOP
10:55 - 11:00 #18482 - SP027 Somatic complaints in survivors after Typhoon Haiyan 2013 in the Philippines.
SP027 Somatic complaints in survivors after Typhoon Haiyan 2013 in the Philippines.

Background

Somatic complaints (i.e., somatization symptoms and pain) in survivors of natural disaster are frequent symptoms and a complicating factor in the treatment of these patients.

The main objective of this study is to analyze the prevalence of possible somatic complaints in survivors during phase 3 post Typhoon Haiyan 2013 in the Philippines.

Methods

One month after-disaster, between 23th of November  and 22th of December  2013, ARES Emergency Medical Team Type 1 Fixed have managed health care of survivors in Esteban – Burauen (Leyte - Eastern Visayas) and collected data: anagraphic data, prevalent symptoms and final diagnosis of these survivors. We defined pssible psychosomatic complaints those cases in which the prevalent symptom was either chest pain or abdominal pain or headache or malaise or hypertension and it was not possible to obtain an organic diagnosis after the diagnostic pathway. We analyzed the prevalence of psychosomatic complaints in our population and by using simple logistic regression we looked for predictive factors for or against the diagnosis of psychosomatic symptoms.

Results

1890 patients were visited: median age 31 (standard deviation 24), 54% female. 407 patients (21%) had possible somatic symptoms (40% abdominal pain, 25% chest discomfort/pain and palpitations, 19% headache, 11% malaise and 5% hypertension). 225 of these 407 patients (55%) were diagnosed as psychosomatic complaints (12% of the entire study population). The predictive factors for diagnosis of psychosomatic symptom were: malaise with OR of 1.40 (95% CI 1.15-1.71, p<0.01), headache with RR of 1.34 (95% CI 1.11-1.62, p<0.01), abdominal pain with RR of 1.06 (95% CI 0.89-1.26, p=0.5) and hypertension with RR of 1.25 (95% CI 0.91-1.72, p=0.2). The predictive factor against diagnosis of psychosomatic symptom was chest discomfort/pain and palpitations (RR 0.54, 95% CI 0.41-0.73, p<0.01).

Discussion and conclusions

The importance of diagnosing a psycosomatic complaint in patient who experinced natural disaster is the possibility of special treatment options. In the literature the prevalence rates of psycosomatic complaints, such as patients presenting persistent pain symptoms, after natural disaster range from 10 to 50%. Our data confirmed this moderately high prevalence,  in particular in a selected subgroup of patients with pain and/or malaise.

Elisa ANDREOLI, Andrea BARTOLUCCI, Vincenzo G MENDITTO (Ancona, ITALY), Marta BUZZO, Francesca RICCOMI, Mattia SAMPAOLESI, Alessia RAPONI, Lara MONTILLO, Francesca FULGENZI, Sirio LOMBARDI, Alessandro MOR, Mario CAROLI
11:00 - 11:05 #18488 - SP028 Comparing training techniques in personal protective equipment use.
SP028 Comparing training techniques in personal protective equipment use.

Introduction:

While an emphasis has been placed on the importance of personal protective equipment (PPE), there are no standardized PPE training guidelines for EM physicians, though many hospitals require brief in-person annual trainings.  Physicians’ response to hazardous material events require PPE utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training is crucial. In the event of a real event, circumstances may not allow for an in-person presentation and an accessible video training may provide a useful alternative.

 

Methods:

A randomized trial was performed with sixteen EM residents divided into two sets of groups, with Groups 1 and 2 viewing a demonstration video and Groups 3 and 4 receiving a separate in-person training. The groups then donned and doffed while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool.

 

Results:

Donning

During donning, the four groups were evaluated on fourteen individual critical tasks.  These tasks were meant to happen in sequence and were specifically included in both the video and in-person trainings.

Groups 1 and 2 (video trained) had a total of nine failures out of fifty-five evaluated possibilities - an error rate of 16.0% (95% CI 11.2% to 32.0%).  Frequently failed tasks involved checking the PAPR for functionality, and not performing a final Buddy check prior to entering the decontamination showers.

Groups 3 and 4 (in-person trained) had a total of eleven failures out of fifty-six evaluated possibilities - an error rate of 19.6% (95% CI 8.6%-28.5%).  Most frequently failed tasks also involved PAPR inspection and final Buddy check but had additional common failures in checking vital signs and providing hydration during the process.

Using a Fisher’s exact test to compare the number of failed demonstrated a two-tailed P value of 0.81, demonstrating no statistically significant difference between donning errors in the two sets of groups.

 

Doffing

During doffing, each of the four groups were evaluated on eleven individual critical tasks, also meant to happen in sequence.

Groups 1 and 2 had a total of fifteen failures out of forty-four evaluated possibilities with an error rate of 34.1% (95% CI 21.8% to 48.9%).  The failed tasks were largely evenly distributed.

Groups 3 and 4 had a total of twelve failures out of forty-four evaluated possibilities - an error rate of 27.3% (95% CI 16.2% to 42.0%).  Frequently failed tasks involved the removal of the PAPR hood and rechecking vital signs.

A Fisher’s exact test demonstrated a two-tailed P value of 0.64, showing no statistically significant difference in doffing errors between the two sets of groups.

 

Discussion:

In this pilot study, video and in-person training were equally effective in preparing residents for donning and doffing Level C PPE, with no statistically significant difference between the error rates in each modality.  Further research into this subject with an appropriately powered study is warranted to determine if this equivalence persists.

Richard James SALWAY (New York City, USA), Trenika WILLIAMS, Camilo LONDONO, Kristi KOENIG, Bonnie ARQUILLA

Monday 14 October

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EPOSTER 2.3
10:45 - 11:05

ePoster 2.3 - Short Oral Presentation - Screen 3

10:45 - 10:50 #17980 - SP029 Prospective study using a combined didactic and web-based learning curriculum to enhance emergency medicine education.
SP029 Prospective study using a combined didactic and web-based learning curriculum to enhance emergency medicine education.

Background:


Intern doctors are required to complete a term of at least eight weeks in emergency medical care in Australia to gain general registration.  This requirement along with a significant increase in medical graduates in recent years has created challenges in delivering a quality educational experience for intern doctors rotating through busy emergency departments.  This study attempts to assess the effectiveness of a blended emergency medicine intern education program that incorporates web-based learning into traditional classroom-based didactic sessions.

Methods:


This prospective study involved a convenience sample of intern doctors doing their emergency medicine term at two urban Australian emergency departments between April 2015 and January 2017.  Participation in the study was voluntary.  The Emergency Department General Education (EDGE) program is an emergency medicine intern education program that utilises a blended curriculum which incorporates web-based modules into weekly didactic and skills sessions.  All intern doctors rotating through the emergency departments of each study site hospital are given protected off the floor time each week to attend the program's educational sessions.  The program runs throughout the ten-week emergency medicine term and is run five times each academic year.  All interns are given access to the program's corresponding web-based learning modules (www.moodle.learnem.com.au) with completion of the web-based material being voluntary.

To assess change in medical knowledge base during the program, participants were administered two multiple choice examinations covering a variety of emergency medicine topics at the beginning (Week 1) and during the final week (Week 10) of the term.  To determine the study's primary endpoint, the impact of the program's web-based resources on improving participants' emergency medicine knowledge base, the median % of online modules completed by participants (75%) was used as a cut off to create two groups; those that completed < 75% and those that completed >75% of the web-based modules.  Student T-test was used to compare the improvement between Week 1 and 10 scores for all interns as well as the improvement between the two groups.  Mean Week 1 and Week 10 examination scores, Standard Deviation, and 95% confidence intervals (CI), were carried out for the two groups.  Intern satisfaction with the program was also assessed using a satisfaction survey.

Results:


The Average examination score obtained in Week 10 (80%) for all participating interns (N=85) was significantly greater than that achieved in Week 1 (68%; P<0.001).  The % improvement between the Week 1 and Week 10 scores of those that completed <75% (N=42) of web-based modules (16% mean; 95% CI 12-20%) and those that completed >75% (N=43) of web-based modules (27% mean; 95% CI 20-34%) showed a statistically significant difference (p=0.03).  Interns when surveyed were also highly satisfied with all aspects of the EDGE program. 

Discussion & Conclusions:


Educational programs that incorporate web-based learning into didactics have several advantages over traditional lecture-based education and have shown promise in the literature.  This study of a blended curriculum that utilizes web-based learning material shows promise in enhancing intern emergency medicine education.

Ryan WINDISH (Brisbane, AUSTRALIA), Peter STUART, Raymund DE LA CRUZ, Alistair MURRAY
10:50 - 10:55 #18771 - SP030 The Impact of Clinical Supervision Shifts on the Resident Supervision Index in the Emergency Department of Qatar.
SP030 The Impact of Clinical Supervision Shifts on the Resident Supervision Index in the Emergency Department of Qatar.

Background: Clinical supervision (CS) is an important foundational requirement to maximize education and assure patient safety. The resident supervision index (RSI) has been proposed as a validated tool in GME programs in the United States to measure the quality of CS. CS in a busy emergency department (ED) setting can be challenging due to the demands of clinical service.

Aim/Objectives: The Impact of Clinical Supervision Shifts on the RSI in the ED

 Method: We implemented special four hours shifts to commit faculty time for CS and measured its impact on the RSI. The study was done in a busy academic ED in Qatar with an annual patient attendance of around 450,000 and staffed by around 240 emergency medicine (EM) physicians including 48 residents and 58 fellows.

Results: A total of 336 responses of individual CS encounters were collected over a period of 8 months of CS shifts. The CS encounters were a mix of case discussion, review of test results, supervision of clinical procedures, WBAs and Ultrasound. The faculty was fully involved in patient care in 20.8% of encounters, partially involved in 46.4% and offered advice in 25.6%. The CS contributed to the understanding of the case by the supervisee in 94.0%. The CS resulted in significant impact on all aspects of the RSI – changes were noted in history in 12.2%, examination findings in 14.4%, interpretation of diagnostic data in 23.1%, diagnosis in 13.6%, overall assessment in 21.6% and in the management plan in 35.1%.

 

Discussion:  Unlike other instruments to assess the quality of supervision, RSI provides quantitative measures of resident supervision. Better supervision will help residents to become skilled physicians and will also help the importantly in patient care.

Conclusion:  

CS shifts in a busy ED resulted in a significant overall impact on the RSI and have the potential to offer major benefits to the educational experience of learners and to patient safety.

 Further studies are recommended to assess the use of RSI to assess outcomes of educational programs on patient’s outcomes

Ayman HEREIZ, Khalid BASHIR (Doha, QATAR), Saleem FAROOK, Mohamed Ahmed SEIF MOHAMED, Thomas PROF. STEPHEN
10:55 - 11:00 #19289 - SP031 Pulseless electric activity as the last rhythm recorded before first adrenaline administration is associated with sustained return of spontaneous circulation in out-of-hospital cardiac arrest cases with adrenaline administration.
Pulseless electric activity as the last rhythm recorded before first adrenaline administration is associated with sustained return of spontaneous circulation in out-of-hospital cardiac arrest cases with adrenaline administration.

Backgrounds and Aims: Adrenaline is administered to patients with out-of-hospital cardiac arrest (OHCA) after basic life support and/or advanced airway management. Time interval between start of CPR by emergency medical service (EMS) and adrenaline administration varied depending on regions, levels of EMS and circumstances of OHCA. It is not rare that ECG rhythm conversion from the initial rhythm to other rhythms are recorded during the BLS period. The first goal of basic and advanced life supports in OHCA cases is sustained return of spontaneous circulation (SROSC) although benefit of each resuscitation procedure should be determined by neurologically favourable outcome. This study aimed to identify the factors associated with SROSC in OHCA groups with adrenaline administration before and after hospital arrival (prehospital and in-hospital first adrenaline groups), with consideration of ECG rhythm changes before adrenaline administration.

Methods: In this retrospective analysis of prospective data collection, we extracted the data for 3,729 adult (≥ 8 y) OHCA cases with adrenaline administration before hospital arrival and 4,070 cases with adrenaline from the population-based OHCA data that were prospectively collected during the period of 2011‒218. Univariate and stepwise multivariable logistic regression analysis were applied to disclose the factors associated with SROSC.

Results: The rates of ECG rhythm conversion in prehospital and in-hospital first adrenaline groups correlated with the initial rhythm (P <0.01): 59.5% and 72.9%, respectively in cases with ventricular fibrillation/tachycardia (VF/VT) as initial ECG rhythm , 24.3% and 43.0% in pulseless electric activity (PEA), 7.0% and 5.6% in asystole. In univariate analyses, both initial rhythms and the last rhythms recorded before first adrenaline administrations were associated with SROSC (P <0.01). However, the rate of SROSC was highest when the initial ECG rhythm was VF/VT (43.1% and 35.9%, in prehospital and in-hospital first adrenaline groups respectively) and when the last rhythm recorded before adrenaline administration was PEA (46.1% and 35.9%.respectively). Stepwise multiple logistic regression analyses revealed that PEA as the last rhythm recorded before adrenaline administration was better predictor of SROSC than VF/VT as initial ECG rhythm and that an interaction for SROSC exists between the initial and last ECG rhythms. Any prehospital defibrillation attempt before the first adrenaline administrations was not a major factor associated with SROSC: P = 0.23 and P = 0.69, in prehospital and in-hospital adrenaline groups, respectively. The overall rate of SROSC in the prehospital first adrenaline group (24.9%, 928/3729) was higher than that in the in-hospital first adrenaline group (15.8%, 644/4070).

Conclusions: Rhythm conversions to PEA before first adrenaline administration are likely to be associated with SROSC. PEA as the last rhythm recorded before adrenaline administration is a good predictor of SROSC.

Hideo INABA, Kurosaki HISANORI (Kanazawa, JAPAN), Kohei TAKADA, Keisuke OHTA, Yukihiro WATO
11:00 - 11:05 #19072 - SP032 The effectiveness of teaching limited compression ultrasound for diagnosing lower extremity DVT in primary health care.
SP032 The effectiveness of teaching limited compression ultrasound for diagnosing lower extremity DVT in primary health care.

Background: According to current literature a limited compression ultrasound (LCUS) protocol is safe to diagnose or exclude lower extremity deep venous thrombosis (DVT). It is a good option to a whole leg ultrasound performed by a radiologist especially in remote health care units where the availability of radiological services is limited and also in emergency department performed by emergency physician (EP).

Objective: To determine whether teaching LCUS to general practitioners (GP) reduces the number of patients with a suspected lower extremity DVT referred to a hospital for US examination safely.

Methods: During 2015-2016, a physician with 5 years of experience in diagnostic US (author Hannula) trained the GPs (n=13 working in Saarikka Primary Care Public Utility (catchment area 18.000 inhabitants) to use LCUS. The number of annual referrals due to a suspected DVT from Saarikka to the closest hospital were evaluated before and after training. The incidence of DVT was considered to be constant, thus the reduction of referrals was interpreted to happen because these patients were diagnosed and treated in primary health care without referring them to hospital. Safety was evaluated by examining all patients from Saarikka area who were diagnosed pulmonary embolism (PE) in nearest hospital during study years and following 3-month periods. Also patients referred to consultant radiologist were examined to find any possible false negative DVTs in LCUS.

Results: In 2014, the number of annual referrals due to a suspected DVT was 60. In 2017 the amount had reduced to 16 with a decrease of 73,3%. The incidence of referrals per 1000 person-years decreased from 3.21 to 0.89. (IRR 3.58, 95% CI 2.04 – 6.66, p<0.001). The annual numbers of PEs were 12 and 23 respectively. None of PE patients had a LCUS performed prior to diagnosis.  There were 13 and 16 referrals to consulting radiologist respectively with no false negative DVTs found.

Conclusions: Teaching a LCUS protocol to GPs seems to effectively and safely reduce the number of referrals to hospital due to a suspected DVT.

Ossi HANNULA (Jyväskylä, FINLAND), Harri HYPPÖLÄ, Suvi RAUTIAINEN, Ritva VANNINEN

Monday 14 October

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EPOSTER 2.4
10:45 - 11:05

ePoster 2.4 - Short Oral Presentation - Screen 4

10:45 - 10:50 #18477 - SP033 Mdivi-1 protects CD4+T cells against apoptosis via balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in sepsis.
SP033 Mdivi-1 protects CD4+T cells against apoptosis via balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in sepsis.

Background:

Apoptosis of CD4+T cells plays a central role in the progression of sepsis because it is associated with subsequent immunosuppression and the lack of specific treatment. Thus, developing therapeutic strategies to attenuate apoptosis of CD4+T cells in sepsis is critical. Several studies have demonstrated that Mdivi-1, which is a selective inhibitor of the mitochondrial fission protein dynamin-related protein 1 (Drp1), attenuates apoptosis of myocardial cells and neurons during various pathologic states. The present study revealed the impact of Mdivi-1 on apoptosis of CD4+T cells in sepsis and the potential underlying mechanisms. We hypothesized that Mdivi-1 ameliorated apoptosis in CD4+T cells by re-establishing mitochondrial fusion-fission balance and preventing the induction of endoplasmic reticulum stress in experimental sepsis.

Methods:

It is an original study. We used lipopolysaccharide (LPS) stimulation and cecal ligation and puncture (CLP) surgery as sepsis models in vitro and in vivo, respectively. Apoptosis and cell viability of CD4+T cells were assessed by TUNEL assay and CCK8 assay. Protein levels were measured by western blotting. And mitochondrial morphology was observed by electron miscrosope.

The data were represented as the mean ± standard deviation (SD) using PSS (version 20.0). A one-way ANOVA was used to analyze significant differences between three or more groups and an unpaired Student’s t-test was used to analyze significant differences between two groups and significance was defined as P<0.05. GraphPad Prism 6 (San Diego, CA, USA) were used for the figure design.

Results:

Firstly, Mdivi-1 increased the cell viability of CD4+T cells and attenuated apoptosis of CD4+T cells both in vitro and in vivo. Secondly, the potential mechanism underlying the protective effect of Mdivi-1 involved Mdivi-1 re-establishing mitochondrial fusion-fission balance in sepsis, as reflected by the expression of the mitochondrial fusion proteins MFN2 and OPA1, Drp1 translocation, and mitochondrial morphology, as observed by electron microscopy. Moreover, Mdivi-1 treatment reduced reactive oxygen species (ROS) production and prevented the induction of endoplasmic reticulum stress (ERS) and associated apoptosis. After using tunicamycin to activate ER stress, the protective effect of Mdivi-1 on CD4+T cells was reversed. Together, Mdivi-1 attenuated apoptosis of CD4+T cells is probably through re-establishing mitochondrial fusion-fission balance and prevented the induction of ER stress.

Discussion and Conclusion:

Recent studies and clinical findings have demonstrated that apoptosis of T lymphocytes has a considerable involvement in immunosuppression and is critically related to the outcome of sepsis. Here, our study showed that apoptosis in CD4+ T cells was increased after LPS administration and CLP surgery. Consequently, it is urgent to develop novel therapeutic strategies to attenuate apoptosis in CD4+ T cells during sepsis to affect the outcome. Our results demonstrated that Mdivi-1 protected against apoptosis of CD4+T cells and balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in experimental sepsis are probable mechanisms involved in it. Mdivi-1 is a probable novel therapeutic strategy that targeted apoptosis in CD4+ T cells to affect the outcome of septic patients.

You WU, Lu ZHONG-QIU (Wenzhou, CHINA)
10:50 - 10:55 #19033 - SP034 An observational study about the performance of the blood enteroviral polymerase chain reaction test in the management of young febrile infants.
SP034 An observational study about the performance of the blood enteroviral polymerase chain reaction test in the management of young febrile infants.

Background: young febrile infants with microbiologically confirmed viral infections, such as influenza, present a low risk of a concomitant invasive bacterial infection (IBI). Little is known about the value of the blood enteroviral polymerase chain reaction (be-PCR) test in the emergency department (ED) management of these patients.

Objectives: to analyze the prevalence of IBI (bacterial pathogen in blood or cerebrospinal fluid) and non-IBI (urinary tract infections [UTIs] and bacterial gastroenteritis) in infants with fever without source (FWS) and a positive or negative be-PCR. To compare the length of stay and the length of antibiotic treatment in hospitalized infants.

Design/Methods: secondary analysis of a prospective registry that includes all the infants ≤90 days of age with FWS attended in a pediatric ED. We analyzed those infants attended between September 2015 and August 2018 with at least blood and urine cultures and a urine dipstick performed.

Results: a be-CRP was performed in 545 of the 638 infants (85.4%). Infants with and without this test performed were similar in relation to their general appearance and age. A positive result was obtained in 153 (28.0%), with seasonal variations (42.1% in May-July vs 20.1% during the rest of the year, p<0.01).

Global prevalence of IBI and non-IBI was 1.1% (95% CI: 0.3-1.9%) and 16.9% (95% CI: 14.0-19.8%). No patient with a positive be-PCR was diagnosed with an IBI (vs 1.5% [95% CI: 0.3-2.7%] of those with a negative be-PCR; p=0.19). Prevalence of IBNI was higher in infants with a negative be-PCR (16.8% [95% CI: 13.1-20.5%] vs 2.0% [95% CI: 0-4.2%] in those with a positive test [p<0.01]). Two other infants were diagnosed with a clinical sepsis with no microbiological confirmation; both had a negative be-PCR.

Among the 245 hospitalized infants (38.4%), 178 received antibiotic treatment (72.6%). Length of hospitalization and length of antibiotic treatment were higher in those with a negative be-CRP (4.90 vs 3.23 days and 4.74 vs 2.17 days, respectively (p<0.01). Differences were also observed among infants without leukocyturia (UTI non suspected): 4.56 vs 3.18 days and 4.15 vs 1.97 days, respectively (p<0.01).

Conclusion: the be-PCR identifies a group of infants ≤90 days old with FWS and a very low risk of IBI. Its inclusion in the management of these patients can also reduce the length of hospitalization and of antibiotic treatment in hospitalized infants.

Borja GOMEZ (Barakaldo, SPAIN), Carla PINTOS, Leire BONILLA, Javier BENITO, Santiago MINTEGI
10:55 - 11:00 #19089 - SP035 An observational study of intravenous drug users presenting with groin swelling/pain to the Emergency Department.
SP035 An observational study of intravenous drug users presenting with groin swelling/pain to the Emergency Department.

Background

 

Intravenous drug users (IVDUs) commonly present to the emergency department (ED) complaining of pain and/or swelling in the groin after recent injection. Clinicians concerns include necrotising fasciitis, psuedoaneurysms, abscess and DVT. There is little data available on how common these diagnosis are or what antibiotics to give. Therefore, decisions regarding imaging, antibiotics and specialty involvement are challenging. This study aimed to address this by answering the following questions: what is the best antibiotic to give, do they need imaged in the ED and how do we identify the particularly sick patient?

 

Methods

This was an observational study of patients presenting to the ED at a large tertiary hospital in Aberdeen, Scotland. Those patients that were included attended the ED between 1st January 2015 and 31st December 2016 and had a diagnosis of ‘local infection of skin and cutaneous’, ‘cellulitis’, ‘other bacterial infections’, ‘cutaneous abscess’, ‘necrotising fasciitis’, ‘septic shock’ or ‘septicaemia’ or had a CT or USS in the ED.

 

Patients who did not present with pain and/or swelling of the groin and a history of recent intravenous drug injection were excluded, as were those with no microbiology samples.

 

The remaining group consisted of 30 patients. Documentation, radiology and laboratory results were analysed for these patients.

 

Results

Within the 30 patients, 13 different combinations of antibiotics were administered. 11 patients were bacteraemic. Samples obtained from blood cultures, deep tissue samples, pus/fluid samples and superficial samples all grew similar organisms, with a significant presence of anaerobes, as well as Staphylococcus, Streptococcus and gram negative bacteria.  

 

3 patients had a pseudoaneurysm (one of which was not identified on CT as an abscess was compressing the vessel), 5 had features of necrotising fasciitis on CT and required multiple debridements, 1 had necrotising myositis, 12 had an abscess and 11 had a DVT. 6 required HDU or ICU care.

 

Patients with significant pathology were difficult to recognise. Most were given a low triage category, had relatively normal observations and only mildly raised lactates even if they ultimately required theatre from the ED and then ICU. A LRINEC score of ≥ 6 or 8 was not a good discriminator of need for urgent theatre but none of those who had a score of <6 had time critical findings on CT or at theatre. In 4 out of the 5 cases of requiring urgent repeated debridments in theatre, the CT in the ED did change management because it had not been clinically apparent how significnant the pathology was.

 

17% of these patients have subsequently died (as of January 2019).

 

Conclusions

Based on the organisms that were grown and the resulting sensitivities, if the patient does not warrant necrotising fasciitis specific antibiotics, Flucloxacillin 2g IV and Metronidazole 500mg IV are advised, with Vancomycin to be used in cases of penicillin allergy.

 

A substantial proportion of these patients will have significant time-critical pathology and it is challenging to clinically identify this. We therefore propose that all these patients should have CT angiography in the ED.

 

Heather GRAY (Aberdeen, UK), Caroline ROBINSON
11:00 - 11:05 #19253 - SP036 CHARACTERISTICS OF THE PATIENT WITH BACTERIEMIA IN EMERGENCY DEPARMENT.
SP036 CHARACTERISTICS OF THE PATIENT WITH BACTERIEMIA IN EMERGENCY DEPARMENT.

INTRODUCTION

The bacteriemia is an important cause of morbidity and mortality in spite of the availability of a powerful antimicrobial therapy and the advances in the support attention. In the Hospitable first aid services, after the clinical evaluation of the feverish syndromes there is habitual the achievement of complementary tests, between which they emphasize the capture of hemocultivos.

TARGETS 

Main: To evaluate the patient's profile with bacteriemia in our health area 

Secondary: To determine the most frequent comorbidities that these present.

 

METHODOLOGY 

Observacional has designed an epidemiologic study to himself with retrospective character, in our hospital that is classified as of the second level and a population of 250000 inhabitants attends. The firs aid service receives approximately 9000 urgencies a month. There were selected patients who consulted for feverish syndrome in the year 2017 and it extracted them to itself hemocultivos. There were checked the case histories of the chosen episodes, variables being gathered as: age and sex, microorganism that isolated itself in the hemocultivo, pathologies previous to the patients, established treatment, I number of returns and mortality.

 RESULTS 

131 patients included with hemocultivos positives. The entire distribution of the sample for sex belonged to 73 males (55,7 %) and 58 women (44,3 %), being the median of age of 76 years, the minimal age 11 and the maxim 97. Of the obtained sample, 14 patients re-entered after being discharged and the mortality in whole was 10,7 %.

As for previous pathologies that they were presenting, it was obtained that 80 (61,06 %) was diagnosed of HTA, their 25 (19,08 %) of DM. As for the cardiovascular diseases, their 28 (21,37 %) had arrhythmias precedents, 6 (4,58 %) had suffered previous IAM, 7 (5,34 %) was presenting cardiovascular disease and 9 (6,87 %) heart failure. If we speak about respiratory illnesses, we are that their 19 (14,50 %) had been diagnosed previously of EPOC and 3 (2,29 %) of bronquiectasias. As for the renal illnesses, 28 of them were presenting ERC (21,37 %), receiving 4 of them hemodiálisis. If we speak about present digestive illnesses in our patients' sample, their 5 (3,81 %) was presenting hepatopatía established and 2 (1,52 %) ulcus. Finally as for the illnesses of neurological origin, their 23 (17,55 %) was presenting cerebrovascular illness and 20 (15,26 %) dementia.

CONCLUSIONS 

The bacteriemias collaborate to a high morbimortalidad incidence. In our series we obtained that the patient's profile is usually a 76-year-old male, with some associate comorbidity, being the pathology more often associated the HTA. On having analyzed the most frequent pathologies for systems, we obtain that the most frequent pathology associated with our patient's profile is that of cardiovascular origin, followed by the neurological one, in the third place the renal one, being the least frequent the digestive one

Alba HERNANDEZ SANCHEZ, Gaelia BORNAS CAYUELA, Sergio Antonio PASTOR MARÍN, Elena Del Carmen MARTÍNEZ CÁNOVAS, Jose Andres SANCHEZ NICOLAS, Maria Encarnacion SANCHEZ CANOVAS, Pascual PIÑERA SALMERÓN (MURCIA, SPAIN)

Monday 14 October

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EPOSTER 2.5
10:45 - 11:05

ePoster 2.5 - Short Oral Presentation - Screen 5

10:45 - 10:50 #18323 - SP037 Comparison of a subjective triage and Emergency Severity Index.
SP037 Comparison of a subjective triage and Emergency Severity Index.

Background: A three-level subjective triage was used to sort patients at the Emergency Department of University Hospital Motol, Prague, until 2018. P1 priority was defined as an emergency (a life- and/or health-threatening condition) to be seen by a physician immediately, P2 as an urgent case to be seen within an hour and P3 as conditions where the care can be delayed according to the current capacity. This was replaced by an objective triage using Emergency Severity Index v. 4 in 2018. Results of both approaches were compared during a one-month period.

Methods: Triage nurses were instructed to triage all the patients using both conventional subjective triage (P1-P3) and ESI v. 4 (P1-P5) and record both the priorities during December 2017. Former subjective P1 priority was replaced by P1 and P2 priorities, P2 by P3 and former P3 by new categories P4 and P5. Their decision making was supported by a paper ESI flow-chart and a computer application.

Results: Both priorities were recorded in 1,010 out of total 1,782 patients (56.7 %), 376 out of them were admitted to the hospital (37.2 %). The average priority using a subjective triage was 2.37 (median 2) and 3.11 using ESI (median 3). The correlation between both priorities was 0.71 (p < .00001). The new ESI priority was, in comparison to the previous subjective triage, lower in 62.9 %, the same in 35.0 % and higher in 2.1 %. A priority obtained by a subjective triage corresponded to ESI as stated above in only 62.2 % cases, in 33.7 % cases (340 cases, 139 out of them were admitted to the hospital, i.e. 40.9 %) it can be evaluated as a possible undertriage and in 4.1 % cases as an overtriage.

Discussion & Conclusions: Despite inevitable errors when using any objective triage system, a subjective triage, although done by an experienced triage nurse, might be burdened by errors in approximately 37 % cases, therefore a more sensitive five-level triage system using objective criteria and values is highly recommended.
Jan BYDŽOVSKÝ (České Budějovice, CZECH REPUBLIC)
10:50 - 10:55 #18345 - SP038 Direct Admission to the Intensive Care Unit from the Emergency Department and Mortality in Critically ill Hematology Patients.
SP038 Direct Admission to the Intensive Care Unit from the Emergency Department and Mortality in Critically ill Hematology Patients.

Background: The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care.

Methods:Post hoc analysis derived from a prospective, multicenter cohort study of 1,011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011.The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90 day-survival.

Results: Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95%CI: 0.45-0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95%CI: 0.45-0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95%CI 0.60-0.99). By contrast, in the propensity score matched sample of 402 patients, direct admission was not associated to in-hospital mortality (adjusted OR: 0.92; 95%CI: 0.84-1.01).

Conclusions: In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.

Olivier PEYRONY (Paris), Sylvie CHEVRET, Anne-Pascale MEERT, Pierre PEREZ, Achille KOUATCHET, Frédéric PÈNE, Djamel MOKART, Virginie LEMIALE, Alexandre DEMOULE, Martine NYUNGA, Fabrice BRUNEEL, Christine LEBERT, Dominique BENOIT, Adrien MIROUSE, Elie AZOULAY
10:55 - 11:00 #19262 - SP039 Experimental use of machine learning to generate next-activity recommendations in the emergency department.
SP039 Experimental use of machine learning to generate next-activity recommendations in the emergency department.

Background

Patients in the emergency department (ED) need a diagnostic work-up from complaints upon presentation to a correct treatment. The intent is to recognize frequently occurring diagnoses and to not miss serious, potentially life-threatening disorders. Emergency physicians continuously refine information to rearrange the probabilities of seriousness and likelihood of potential diagnoses. They consider the patient characteristics and results of technical investigations and implement clinical decision rules. However, the environment of the ED (e.g., the availability of resources) and the personal characteristics of the physician (e.g., experience, memory, interpersonal skills) also contribute to the decision-making.  Therefore, a secondary source of knowledge proposing the next activity to perform (e.g. take an X-ray) and reflecting all preceding experiences with similar patients in the setting of the specific ED would be an improvement.

Methods

Design Science methodology was applied to develop techniques that generate recommendations for the next activity to be executed for patients in an ED, using a combination of historic data, process management and machine learning. In this project, historic data were used from the ED of the Maria Middelares hospital in Ghent, Belgium consisting of 41657 patients. For each patient, the timeline of all registered events in diagnosis and treatment was reconstructed, starting from the registration at the entrance and ending with either a discharge or hospital admission. Additionally, keywords (e.g., “anemia” in the medical history) and other data values (lab and X-ray) were identified.

Forty strategies that each prioritize different similarities between the current and historic patients based on either activities, data or both, were prototyped to generate probabilities that serve as next-activity recommendations. They were trained on a subset of the patients and evaluated by comparing the predicted with the actual next activities of the other patients. The evaluation criteria were the calculation time and five performance measures:  rank, accuracy, brier score, log loss and rank score.

Results

The Design Science methodology identified 1350465 data events with 625758 activities and 117 unique activities in patient timelines with a maximum of 128 subsequent activities. The best performing strategy achieved an average top ranked recommendation accuracy of 60% and the correct next activity was ranked in the top 3 on average, with an average calculation time of less than 0.4 seconds.

 

Conclusions and future directions

The proposed strategies were fast and sufficiently accurate to help remind emergency physicians of alternatives or forgotten activities, without impacting their decision freedom. These experiments are to be seen as operational process support, i.e. not to try to impose a specific diagnosis or therapy but merely suggesting suitable next activities. It could prevent medical errors and promote a more uniform diagnostic approach. Future research is aiming to further improve the accuracy of the first recommendation and to allow the introduction of clinical pathways. The ultimate goal is to provide real-time recommendations for the possible next-step activities of all patients present at the same time in the ED and for the prioritization of patients, based on their characteristics and results of their preceding processes.

Diederik VAN SASSENBROECK (Ghent, BELGIUM), Steven MERTENS
11:00 - 11:05 #19317 - SP040 A cross-sectional survey among asylum seekers with non-urgent complaints: Why do they seek help in the ED?
SP040 A cross-sectional survey among asylum seekers with non-urgent complaints: Why do they seek help in the ED?

Background

In line with global trends, European countries have witnessed increase usage of Emergency Departments (ED) services for low acuity complaints. Research on ED utilization in Europe has shown that AS comprise a greater proportion of non-urgent ED visits. Although a variety of factors associated with the use of ED services for low acuity complaints, studies have yet to examine the reasoning underlying hospital-based ED usage for low acuity complaints among patients with asylum seeker (AS) status.

Methods

We conducted a prospective cross-sectional, single center study. Data was collected during 01/12/2016 and 31/07/2017 among AS and Swiss residents attending the ED of the University Hospital, Bern (Switzerland). The survey included questions about motives to present in the ED for low acuity complaints, patients and the treating physicians were asked to answer a questionnaire.

Study participation was voluntary, free of any compensation and individual verbal and written patient consent was obtained before answering the survey. The study was presented to and approved by the regional ethics committee of the Canton of Bern, Switzerland.

Results

AS and Swiss residents differed in several reasons for seeking care in the ED. 30.2% of the AS patients reported to have no knowledge about the Swiss healthcare system (HCS). The perception of medical urgency as reported by the AS and the treating physician showed a significant mismatch, e.g. only 14.2% of the AS-patients perceived their problem as non-urgent in contrast to 43.3% given by the treating ED physician.

With more than half of the AS, direct communication was impossible and in 70.2% of this cases family and friends were used as translators.

Outcomes, like length of stay (LOS), discharge type, and time of visit did not differ between the two groups.

Conclusion

Lacking knowledge about the healthcare setting in the reception country, language barriers, and the perceived urgency of medical care are the main reasons for AS to seek care in ED for primarily low-acuity medical issues. In both groups, convenience and the perceived level of urgency played a role in the decision-making to present themselves in the ED.

Measures to increase health literacy and provision of easily accessible primary care could improve quality of care and reduce the usage of ED as primary care providers in AS. Implementation and usage of professional translator service will relieve family and friends from this role and might provide better and equal care.

Karsten KLINGBERG, Adrian STOLLER, Martin MÜLLER, Sabrina JEGERLEHNER, Anne JACHMANN, Adam D BROWN, Aristomenis EXADAKTYLOS , David SRIVASTAVA (Bern, SWITZERLAND)
15:45

Monday 14 October

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EPOSTER 3.1
15:45 - 16:05

ePoster 3.1 - Short Oral Presentation - Screen 1

15:45 - 15:50 #18268 - SP041 Health promotion in emergency departments with a digital tablet: an observational study.
SP041 Health promotion in emergency departments with a digital tablet: an observational study.

Background: In European countries, an increasing number of patients consult the emergency department (ED) instead of a general practitioner for non-urgent primary medical care. These patients may benefit from ED-based preventive care but overloaded ED physicians are reluctant to be involved. The primary objective of this study was to evaluate the proportion of patients accepting a preventive care intervention using a digital tablet (DT) during their ED visits; the secondary objective was to evaluate the proportion of patients benefitting from counselling.

Methods: Single-center observational study conducted in the minor section of a tertiary-care ED in August and September 2018. Inclusion of consecutive patients ≥18 years with decision-making capacity, admitted during the investigator's presence (rotating 8-hour shifts within a 24h/7d schedule). The DT presented a menu of nine validated health questionnaires with, after completion, a personalized report with health recommendations based on individual scores, and links to support material or details of specialized services. The report could be printed or emailed to the patient.

Results presented as proportions, mean and standard deviation (SD) or median and interquartile range (IQR). The ethics committee approved this study.

Results: 500 eligible patients were approached and 317 (63%) included. Median ED length of stay: 5.2h (3.7; 7.6). Mean age: 44 ± 17 years, women: 45%; 98% Swiss residents; 54% professionals and 20% retired; 27% with a postgraduate degree, 83% registered with a GP, of whom 84% had visited at least once in the preceding year. Patients filled a median of 4 (2;9) questionnaires. Questionnaires presented by frequency of choice: 1) physical activity 71%: 55% below the recommendation of ≥2x30 minutes/week of moderate activity; 2) alcohol consumption 62%: 55% at-risk drinkers; 3) 62% tobacco: 53% active smokers and 58% contemplating smoking cessation; 4) diabetes 62%: 14% at high risk of developing diabetes, with 62% accepting a bedside capillary glucose check with one new diabetes diagnosis; 5) vaccination status 60%: 24% not up to date; 6) colon cancer 56%: 26% of those aged 50-69 years never screened by colonoscopy or fecal occult blood testing, and 14% having failed to keep up with screening schedules; 7) HIV 50%: 40% accepting a rapid non-targeted opt-in capillary test; no reactive test;7) interpersonal violence 46%: 21% victims of verbal and/or physical violence, of whom 10% wished to discuss this issue with the ED physician; 9) drug misuse 48%: 35% reporting recent misuse.

Discussion & Conclusions: A majority of patients accepted a digital screening and health-counseling offer, and 50% chose at least four domains. The questionnaires revealed that a significant proportion of this mostly young and active ED population could benefit from advice to improve their health. Although we did not measure the long-term impacts of our intervention, a significant proportion accepted immediate bedside tests for diabetes and HIV. Our results suggest that a DT screening offer would allow the ED to play a complementary role in promoting health in Switzerland. However, further research on its clinical impact is needed before widespread dissemination of this intervention is attempted in Swiss EDs.

Thibaut JOSSEIN (Lausanne, SWITZERLAND), David CAILLET-BOIS , Olivier HUGLI
15:50 - 15:55 #18567 - SP042 Mass casualty incidents digital transformation - a reloaded project.
SP042 Mass casualty incidents digital transformation - a reloaded project.

Background:

Six years ago a mass casualty incident digitalization project began under the acronym SICAD. The aim of the project was to completely transform the mass casualty incident management on the field and remotely by using current communication technology. This implies using a mobile and server solution as well as electronic patient tags. After a long period of extensive testing of all modules and given several technical drawbacks due to the complexity of the overall solution, a completely redesigned project emerges to carry on the future version of the initial project. The new solution is renamed EMERSYS and it is designed primarily for the use of Romanian emergency agencies.

Methods:

The technical backbone of the previous solution was redesigned in terms of modularity and interconnectivity. Initial requirements for the software solutions are set, allowing for each module to receive and output data independently. The previous Parse.com database integration is completely replaced by an SQL database. Trafficked data is managed by a store-and-forward algorithm in order to maintain a steady flow of operation despite probable moments of lack of data signal. Data logging is significantly augmented. The solution also expands in terms of purpose to several individual applications – mobile and web-based – to address both professionals and bystanders. Improvements are also integrated in terms of power efficiency, graphics, software solution size and operation optimization and security.

Results:

Three distinct packages are set. EMERSYS ONE is an entry level pack designed to digitize the mass casualty incident paper chart and integrate several electronic patient tags. It comprises of a dedicated mobile app for prehospital physicians and paramedics and a web-based app for data output. EMERSYS TWO is a professional pack designed to integrate the majority of functions of the project. It addresses all professionals involved as well as bystanders and it comprises of a dedicated extensive mobile app and six distinct web-based apps: 112 Dispatch, Hospitals, Analysis, Press, Simulator and Backoffice. EMERSYS THREE is based on the same structure as the previous pack but it allows for more advanced algorithms and functions for a more detailed integration of the event digitalization.

Discussion & Conclusions:

The current EMERSYS project carries on the purpose of the previous project to take full advantage of the current technology, especially mobile communications technology. Current work is under way to allow for full offline operation. Further tests are also necessary in order to assess a reliable operation of all packs. Moreover, there is a strong need of simulation by professionals and tech team alike, as well as integrating their feedback. This report refers to the current progress in terms of the overall structure and design and modules operability.

Adrian STANESCU (Targu Mures, ROMANIA), Cristian BOERIU
15:55 - 16:00 #18779 - SP043 Needs Assessment for a Pediatric Emergency Medicine Application.
SP043 Needs Assessment for a Pediatric Emergency Medicine Application.

Background: Smartphone applications (apps) have been increasingly utilized by physicians as a tool to supplement and support clinical practice. Barriers to utilization include cost of purchasing the app, user friendliness, lack of specific content, and timeliness of software / content updates. Pediatric Emergency Medicine (PEM) is a specialty that could benefit from a customized mobile app, given nuances in clinical management such as medication dosing or unique age-specific pathology. The purpose of this study was to understand the needs of post-graduate learners as it relates to PEM resources to aid in clinical practice.

Methods: This was a prospective study, and institutional Research Ethics Board approval was obtained. The survey was sent out to all current Emergency Medicine and Pediatrics residents at McMaster University, Canada. Survey questions were related to type of residency, year of training, smartphone and app utilization, and desired content for a new app. For the desired content, participants were requested to list their top 5 items and the responses were then grouped using a theme analysis.  

Results: A total of 35 responses were received (33.7% response rate). 31.4% were from Pediatrics residents, with the remainder from Emergency Medicine. Eighty percent of respondents used Apple’s iOS as their mobile operating system with the remainder using Google’s Android. The top three most commonly used apps were UpToDate (51.4%), MDCalc (42.9%), and Spectrum (22.9%). Spectrum and MDCalc are both free applications available on both platforms, while UpToDate is only offered by paid subscription (whether individually or through an institution).  From the desired topics, the top five themes were related to medication dosing (71.4%), appropriate antibiotic choices (65.7%), treatment algorithms (25.7 %), electrocardiogram (ECG) references (22.9%) and vital sign reference ranges (22.9%).

Conclusion: While there is an abundance of clinical resources available to trainees, mobile apps are a great resource for just-in-time reference. This study provides a starting point to identify what trainees are looking for in an app that is specific to PEM, and can be used to either build a new app or add to an existing one. Further studies would be helpful in understanding the actual utilization of such a resource.

Alvin CHIN (Hamilton, CANADA), Chris SKAPPAK, Shannon THEUNE, Rahim VALANI
16:00 - 16:05 #19035 - SP044 Improving Emergency Department flow: implementation of consultant based triage in a tertiary university hospital.
SP044 Improving Emergency Department flow: implementation of consultant based triage in a tertiary university hospital.

BACKGROUD

Improving patients flow throughout the Emergency Department(ED) is a desirable goal to reduce overcrowding, morbidity and mortality, and to improve patients and operators satisfaction. Several interventions can be made to reduce the throughput patient flow. Our ED is provided with a rapid assessment area (RAA) after standard first level nurse-led triage. Since November 2018 a senior doctor, so called facilitator, was placed in the RAA. The aim of this study was to compare the waiting-to-be-seen time and ED length of stay (LOS) before and after this intervention.   

METHODS

This is a retrospective cohort study conducted in the ED of the San Martino University Hospital, a tertiary referral centre located in Genoa, Italy, accounting of 90.000 annual visit rates. We analysed data of all ED presentations during 5 months before (from November 2017 to March 2018) and 5 months after (from November 2018 to March 2019) the facilitator implementation. Using our local software, waiting-to-be-seen time (from triage registration to first medical contact) and LOS (from triage to ED discharge) of all patients were analysed. The intervention consisted of the presence of the facilitator in the RAA from Monday to Friday for 6 hours/day meeting the peak demand periods since 1st November 2018. Before this date RAA was nurse-led. His function was to commence a diagnostic and treatment plan then reviewed by other physicians. We analysed the times according to the four-grade priority scale attributed at triage as RAA manage the two middle grade of the scale (yellow and green codes) leaving the higher and lower grade (red and white codes respectively) to other pathway. Ethical approval was not needed as non clinical study. Waiting-to-be-seen time and LOS (in minutes) were normally distributed and compared with Student’s t-test.

RESULTS

We analysed 38.402 and 44.204 ED visits from pre and post-facilitator implementation respectively. Waiting-to-be-seen time for yellow and green codes was reduced of 21,3% (from 103 to 81 min,p<0.05) and of 23,1% (from 157.5 to 121min,p<0.05) respectively. LOS for yellow and green codes was reduced of 23.2% (from 328 to 251.7 min,p<0.05) and of 17.3% (from 303.6 to 250.8min,p<0.05) respectively. Red codes waiting-to-be-seen time increased from 6.6 to 10.6min whilst their LOS reduced from 205,6 to 181min (-17.9%). Similarly white codes waiting-to-be-seen time increased from 120.1 to 122.3 and LOS reduced from 205,6 to 181min and from 197.3 to 172.6 min(-14.6%). 

DISCUSSION & CONCLUSION

We found a reduction of both waiting-to-be-seen time and LOS during facilitator implementation period for yellow and green codes whilst red and white codes didn’t seem to be affected in their waiting-to-be-seen time but we  found a reduction in their LOS. This may be related to a beneficial indirect effect of the facilitator on the other physicians reducing their workload for each patient. Even if many other variables should be taken into account, according to these results facilitator helped to significantly boost ED patients’ process. Management of ED patients flow is an important instrument to reduce overcrowding and further strategies should be sought and implemented.

Stefano SARTINI, Luca CASTELLANI (Genoa, ITALY), Marta CASTELLI, Ludovica CESCHI, Luca COLOMBO, Irene MARATONA, Luca MOISIO CORSELLO, Andrea Lorenzo POGGI, Chiara RICCO, Ombretta CUTULI, Paolo BARBERA, Roberto TALLONE

Monday 14 October

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EPOSTER 3.2
15:45 - 16:05

ePoster 3.2 - Short Oral Presentation - Screen 2

15:45 - 15:50 #18374 - SP045 Why do patients with renal colic get hospitalised?
SP045 Why do patients with renal colic get hospitalised?

Abstract: Approximately 12% of patients are admitted at their initial emergency department (ED) presentation with renal colic. After revisit this percentage increases to 33%. Currently there is no clinical prediction model that explains the probability of admission. In 2015, a multivariate analysis was published as an impetus for further research. A retrospective cohort study was conducted at the emergency department (ED) of the UZ Brussel, identifying clinical risk factors for hospitalisation. Using clinical parameters, we can only explain half the variance, implying that other factors contribute significantly to hospitalisation in renal colic.

Methods: On the retrospectively collected dataset comprising 1207 ED visits, descriptive statistics via chi-square for categorical and one-way ANOVA for numerical variables were performed. Four binary multivariate logistic regression analyses were used to identify contributing factors to hospitalisation.

Results: On average, hospitalised patients were 5 years older than patients who received outpatient care.  There is also an increased likelihood of hospital admission at revisit, previous history of renal colic, intercurrent urine tract infection, and hydronephrosis. The total equivalents of morphine recieved are 2,9 ± 0,61 mg for outpatients and 11,0 ± 1,18 mg when hospitalised (n = 1207, p <0,001). Overall admission ratios correspond to literature: 12.5% after the first visit and 31.7% on second presentation at the ED. This percentage doesn’t increase with subsequent revisits.

The first multivariate analysis identified the following relevant clinical parameters as contributor to hospitalisation: age, revisits, use of pain score, use of diclofenac, paracetamol, anti-emetics, tamsulosin, morphine equivalents received (Nagelkerke R² = 0.481). The second used radiological stone characteristics (Nagelkerke R² = 0,121). A calculus of <5 mm is a predictor for outpatient treatment, whereas a stone size >20 mm increases likelihood of inpatient treatment, as is hydronephrosis. The location of the calculus in the pyelo-urethral system was not significant. Laboratory results were used in the third analysis. Combination of C-reactive protein (CRP), presence of acute kidney injury (AKI) and a positive urine culture were significant predictors. Total white blood-cell count (WBC) was a non-significant contributor. (Nagelkerke R² = 0.124).  The final model combined all significant predictors from the previous analyses, achieving Nagelkerke R² = 0.51.

Discussion: These results imply that radiological stone characteristics can only explain variation in hospitalisation or outpatient treatment to a limited extent. Combined with the clinical parameters described above, approximately 50% of the variation in admission number can be explained. Most of these parameters are related to analgesic therapy, so analgesic optimisation is of paramount importance. In our opinion the use of diclofenac and paracetamol does not increase hospitalisation probability; Rather, analgesic therapy is improved upon admission.

Conclusion: With hard-clinical parameters only half the variance can be explained, implying that other factors that were not taken into account in this study may contribute significantly to hospitalisation in renal colic.

Van Hove SAM (brussel, BELGIUM), Evert VERHOEVEN, De Rouck RUBEN, Ives HUBLOUE
15:45 - 15:50 #18343 - SP049 Assessment of the validity and reliability of a new triage tool for avalanche mass casualty incidents: the cardiac arrest avalanche triage tool.
SP049 Assessment of the validity and reliability of a new triage tool for avalanche mass casualty incidents: the cardiac arrest avalanche triage tool.

INTRODUCTION: The widely used standard avalanche triage algorithm (Bogle 2010) does not include provision for mass casualty incidents (MCI) nor does it detail the use of extra corporeal membrane oxygenation (ECMO). This study aimed to produce a reliable and validated triage tool for use in avalanche MCI that included updated recommendations for the use of ECMO– the Cardiac Arrest Avalanche Triage Tool (CAAV).

METHODS: The CAAV tool was developed by a focus group of four experts in avalanche rescue. To assess the validity of the tool, four other experts who had never seen the tool used the tool to assigned a triage category to 45 simulated cases and to compare to their own expert opinion. Reliability of the tool among these experts was calculated using the Fleiss test. To assess the accuracy of the tool in a broad population of rescuers an online simulation was given to avalanche rescue providers who were asked to triage 39 simulated cases using the CAAV tool: results were compared to the triage categories given by the four experts.

RESULTS: The CAAV tool is available at www.medstatstudio.com/studies/project.php?pid=19 . When experts used the tool it agreed with their expert opinion in 97% of cases (95% confidence interval: 93% - 99%). Inter-rater reliability for the experts was 0.86. Among the 115 avalanche rescue providers who completed the online simulation, triage assignment using the tool was correct in 63% (95% confidence interval: 57% to 68%). Only 43% of the non-expert participants had accuracy of greater than 80%.

CONCLUSIONS: In this study the CAAV tool showed adequate validity and reliability in expert hands. However, in the broad population of rescuers the tool showed poor accuracy. Further refinement of the tool and simulation testing procedure is clearly necessary before moving towards trials in the field.

Francesca VERGINELLA, Jeffrey FRANC (Edmonton, CANADA)
15:50 - 15:55 #18999 - SP046 PERCEPTION AND MANAGEMENT OF PAIN BY HEALTH PROFESSIONALS IN AN EMERGENCY SERVICE.
SP046 PERCEPTION AND MANAGEMENT OF PAIN BY HEALTH PROFESSIONALS IN AN EMERGENCY SERVICE.

Introduction: Pain is one of the main reasons for consultation in the Emergency Department, reaching 42.8% of patients who require medical assistance.

Objective: To evaluate the perception and management of pain by healthcare professionals in the Emergency Department of the “Hospital Universitario de La Ribera” (Valencia-Spain)

Methodology: A descriptive, prospective and analytical observational study was performed. Data collection was carried out by means of a survey in which respondents were asked about the transmission of information to the patient on aspects related to pain, systems used to categorize pain, knowledge of protocols and their use in fixed and rescue guidelines, their registration, the system used for their evaluation in the patient, the need to prevent pain, the adequacy of pain treatment in the service and the possibility of improving its approach.

A univariate descriptive analysis and an analytical study were carried out in order to explore whether the professional category influenced the perception and management of pain.

Results: 74.25% of the service workers, mostly women, with an average age of 37.013±10.85 years, were interviewed. The most representative group was nurses (52%). The transmission of information to the patient on aspects related to pain refers to being carried out mainly in a non-written form (always 16%, almost always 38.67% and sometimes 28%). The EVA and EVN scales were the most used to categorize pain in the communicative patient (52% and 41.3% respectively). 53.33% of the participants did not use any method to categorize pain in the non-communicative patient. 61.33% know pain control protocols and use them in both fixed and rescue guidelines. Pain is assessed more frequently by asking the patient than by physiological records. 57.3% consider that pain management in the unit is almost always adequate and 44% think it can always be improved.

Analysis by professional categories showed significant differences in the variables need to promote and prevent pain (p=0.048) (higher in the physicians and lower in the auxiliaries), a system used to categorize pain in the communicative patient (p=0,001) (doctors indicated the EVA scale and nurses the EVN scale), pain recording frequency (p=0.016) (nurses refer to always recording pain and doctors some or few times) and pain evaluation frequency asking the patient (p=0.04) (much higher in nursing assistants and lower in doctors).

 

Conclusions:

In the Emergency Department of the “Hospital Universitario de la Ribera” pain assessment and treatment should be improved in order to unify criteria among professional groups and establish a systematic way of dealing with pain according to the type, severity and characteristics of the patient, implementing and using protocols to improve the approach to pain in patients.

 

 

María CUENCA, Bernia ANDRES, Luis MANCLUS, Immaculada TORMOS , Pedro GARCIA, Jose Luis RUIZ (VALENCIA, SPAIN), Luisa TARRASO
15:50 - 15:55 #18723 - SP050 Is being “competent”enough? Emergency department registered nurses’ disaster preparedness as assessed using Benner’s model of clinical competence.
SP050 Is being “competent”enough? Emergency department registered nurses’ disaster preparedness as assessed using Benner’s model of clinical competence.

BACKGROUND

 

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

 

AIM

 

To assess emergency department registered nurses’ EOP competencies.

 

METHOD

 

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

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

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

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

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

 

RESULTS

 

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

 

CONCLUSION

 

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

Jason MURPHY (Stockholm, SWEDEN), Sofia MAGNUSSON, Tove RINGQVIST, Monica RÅDESTAD, Lisa KURLAND, Anders RÜTER
15:55 - 16:00 #19362 - SP047 Understanding patient perspectives on informed consent for analgesia research in the Emergency Department.
SP047 Understanding patient perspectives on informed consent for analgesia research in the Emergency Department.

Background

 

Acute pain is common in emergency patients.  Acute pain management is an important area for research with previous reports highlighting poor pain management impacting negatively on patient experience, but obtaining consent in these circumstances is challenging. For patients experiencing a health emergency, the capacity to make decisions regarding analgesia and to consent to participate in research can be affected by many factors including co-morbidities, stress, emotion and the illness or injury itself. Consent waivers are often granted in seriously compromised patients, but this process is less clear when the patient is conscious but in severe pain. Furthermore, little is known about the patient perspective. 

 

Methods

 

A face to face survey was completed from February to April 2019 in a UK major trauma centre ED by two interviewers. Additional physiological information was collected from the pre-hospital and hospital patient care record. The survey was approved and registered with University Hospitals Plymouth NHS Trust, CA_2018-19-12.

 

Participants were identified through convenience sampling using the inclusion criteria: aged 18 years or over; Glasgow Coma Scale of 15; presented with a traumatic injury or abdominal pain; had been conveyed to hospital by ambulance; and could recall their pre-hospital treatment. Participants provided verbal consent to be interviewed. Bias between interviewers was minimized through set questions. 

 

The primary outcome was to determine if participants felt they could have provided informed consent at set time points. Secondary measures included patient demographics, physiological and pain data, analgesia and patient perspective comments from open questions. 

 

Results 

 

37 participants were surveyed (20 female, 17 male, aged 18 to >85 years). 95% reported past medical problems, 92% were taking one or more regular medications, with 38% on regular analgesia. Abdominal pain made up 78% (n=28) of participants. 

 

87% of respondents received analgesia in the pre-hospital setting. 97% thought that research to improve acute pain management was a good idea. 

 

78% reported that pain was at its worst before receiving pre-hospital analgesia and 13% reported it was worse on transfer to, arrival at or in the ED. Pain scores were not recorded in 2 participants at initial pre-hospital contact, 6 participants following initial analgesia and in 10 participants at ED triage. 

 

Regarding decision-making for written informed consent, 24% felt they couldn’t have provided consent prior to receiving pre-hospital analgesia, which decreased to 11% after initial pain relief and to 5% in the ED. Comments were themed around inability to process, understand and retain information due to pain. 84% reported that they would have been happy to have consent delayed until arrival at the ED; those with concerns reported medical history, drug interactions and allergies as important considerations. 

 

Conclusion

 

Emergency care analgesia research is important to patients, and several factors influence a patient’s perceived ability to provide informed consent including environment, pain and pre-existing conditions. When planning analgesia research, patient involvement is key to determining the informed consent process. 

Alexandra SLOAN, Kenneth MORRISON (Plymouth, UK), Laura COTTEY, Tim NUTBEAM, Jason SMITH
15:55 - 16:00 #19201 - SP051 THE SYNCHRONY AND SYNERGY BETWEEN PHYSICIAN AND NURSE IMPROVES THE EVALUATION OF THE BED SURGE CAPACITY. EXPERIENCE OF AN ITALIAN DEA-TRAUMA CENTER.
SP051 THE SYNCHRONY AND SYNERGY BETWEEN PHYSICIAN AND NURSE IMPROVES THE EVALUATION OF THE BED SURGE CAPACITY. EXPERIENCE OF AN ITALIAN DEA-TRAUMA CENTER.

Introduction: The Bed Surge Capacity is a very important information in the articulation of all phases of the PEIMAF inside the hospital as the pre-hospital organization. It derives the importance of a more precise and timely detection.

Purpose: To evaluate the accuracy of the bed surge capacity in eighteen hospital departments and the surgical availability of the three DEA, through the real-time detection of the number of beds available/readily deliverable at 2 and 24 h from a hypothetical maxiemergency, through four total simulations (three with regard to phase 1 and one for phase 2) both consist of two detection times (T2 and T24). In particular, we analyzed the accuracy of information when obtained from physicians, nurses individually or from integrated surveys.

Materials and methods: The estimation of hospitalization and surgical capacity of the foundation has been assessed on weekdays and holidays, dividing the beds free/readily deliverable by typology (medicines, surgeries, intensive care and subintensives) and Availability of operating theatres.

The creation of new beds was presumed by the possibility of displacement of patients in a lower level of care than that provided at the time of detection, dislocation of patients in a discharge room with assistance of type Nursing, transfer to hospitals with less intensity and rehabilitation facilities or discharge at home.

Results: While in the operative phase of Phase 1 only the nursing coordinators were involved, in the study phase were enrolled both doctors and nurses, with a greater involvement of the second in the first surveys, 11 Nurses in the first day of the I simulation, to then decrease numerically up to a single IC involved in the last two surveys, as it indicates the development of more attention by the medical staff to the simulation.

It has been noted an increase in the total percentage of patients who could be discharged in case of emergency, passing from 22% T2 of the I simulation to 29% of T24 of the simulation II. The increase of patients in this category in the course of the study is reflected in the fact that in the I and III evaluation, in which an equal number of physicians and nurses have been involved in T2 and T24, there is no significant variation in the percentage between the two Detection times, but they are relevant if the average of the I and III simulation is taken into account (22% versus 27%) With evidence of a 5% increase in the category..

Conclusions: From this preliminary data it can be said that to have a complete indication of the possibility of transfer of the patient, it is necessary to take into consideration both the criteria of medical and nursing, for which the choice must be made in team Medical/Nursing.

The first are more focused on severity pathology, progress of the diagnostic-therapeutic pathway, hemodynamic stability of the patient, the second focalise patient care needs (autonomy, presence of invasive devices, catheters, Principals of O2 Administration). Analytical comparison studies are required for the confirmation of the data.

Iride Francesca CERESA, Gabriele SAVIOLI (PAVIA, ITALY), Valentina ANGELI, Viola NOVELLI, Alba MUZZI, Carlo MARENA, Paolo DIONIGI, Maria Antonietta BRESSAN
16:00 - 16:05 #19411 - SP048 Procedural sedation and analgesia in a Belgian Emergency Department: an observational cohort study.
SP048 Procedural sedation and analgesia in a Belgian Emergency Department: an observational cohort 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 (p=0.023).

 

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. In line with previous studies, ASA class 3 or higher was found to be an independent risk factor for advers events.

Laurens DE GRIM (Breda, THE NETHERLANDS), Hannelore RAEMEN, Koen MONSIEURS
16:00 - 16:05 #19421 - SP052 The August 24th, 2016 Central Italy Earthquake: validation of the “Modified Utstein Template for Hospital Disaster Response Reporting” as a new tool for reporting hospital's reaction to disasters.
SP052 The August 24th, 2016 Central Italy Earthquake: validation of the “Modified Utstein Template for Hospital Disaster Response Reporting” as a new tool for reporting hospital's reaction to disasters.

Introduction: after action reports analyze events and improve knowledge about how to prevent and react to unexpected situations. Anyway, there is no consensus among the templates developed for disaster events reporting and there is not a specific model for reporting hospital disaster response.

Hypothesis: we intended to pilot the use of a new assessment tool for hospital response to natural disasters.

Methods: a data collection tool, focused on hospital disaster response to natural disasters, was created modifying the “Utstein-Style Template for Uniform Data Reporting of Acute Medical Response in Disasters” and tested the reaction of the nearest hospitals to the epicenter after the August 24th, 2016 Central Italy earthquake.

Results: 4 hospitals were included. The completion rate of the tool was of 97.10%. A total of 613 patients accessed the four emergency departments, most of them in Rieti hospital (178; 29.04%). Three hundred and thirty – six patients were classified as earthquake-related (54.81%), most of which with trauma injuries (260; 77.38%).

Discussion: this collection tool proved to be feasible and allowed to retrospectively reconstruct most (97.10%) of the steps of hospital disaster plan deployment and response. Details about activation, patients fluxes, times and actions undertaken were easily reconstructed throughout in-field interviews of hospitals’ managers and consulting patients’ charts. The influx of patients appeared to be quite uniformly distributed across the 4 facilities and, according to our data, hospitals’ capabilities were sufficient to resist the surge.

Conclusions: the Modified Utstein Template for Hospital Disaster Response Reporting is a valid instrument for hospital disaster management reporting. This template could be used for a better comprehension of hospital disaster reaction, debriefing activities, and HDP revisions.

Matteo PAGANINI (Padova, ITALY), Luca RAGAZZONI, Fabio ROSSITTO, Aurora VECCHIATO, Rita BONFINI, Maria Vittoria MUCCIANTE, Alessandra NISII, Francesco DELLA CORTE, Pier Luigi INGRASSIA

Monday 14 October

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EPOSTER 3.3
15:45 - 16:05

ePoster 3.3 - Short Oral Presentation - Screen 3

Monday 14 October

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EPOSTER 3.4
15:45 - 16:05

ePoster 3.4- Short Oral Presentation - Screen 4

15:45 - 15:50 #18527 - SP053 Patterns of abuse in elderly – an underestimated problem at the emergency department.
SP053 Patterns of abuse in elderly – an underestimated problem at the emergency department.

Background: One of the first articles concerning elder abuse was published in 1975. Since then there has been a growing awareness concerning the topic, but there is still a big gap between research and how these findings should be implemented in clinical practice. Medical settings, such as an emergency department (ED), have a potential to be a good location to identify elder abuse because many elderly individuals that have been exposed to abuse need medical expertise to treat their injuries. The main objective of this study was to examine frequency, risk factors and injury patterns of elderly individuals who received care at an emergency department after being a victim to physical abuse.

Methods: The study was conducted as a descriptive, retrospective study where data were collected from medical records during 2011-2012 at Helsingborg General Hospital in the south of Sweden. All patients aged 65 years and above that was seen in the ED were identified and then all patients with the main complaint abuse were included in the study. After all cases of abuse against elderly were identified the medical records for these patients were examined thoroughly to abstract data. Demographic variables such as age, gender and marital status were collected from medical records. Other known risk factors such as psychiatric illness, dementia, stroke and alcohol abuse were registered. Place of injury, if the victim knew the perpetrator, injury patterns and body location, photo documentation of the injuries and if the assault was reported to the police was also abstracted.

Results:  During the study period a total of 39,312 patients ≥ 65 years received care at the ED of Helsingborg General Hospital. Out of those 21 cases of elderly abuse was identified. Several patients had numerous injuries allocated to different body locations. Haematomas were the most frequently documented injury and the head and neck region was the region mostly affected. Some patients showed old scars and haematomas of different ages during the physical examination. Found risk factors were excessive alcohol consumption and comorbidities.

None of the victims had any documented follow-up plan related to the assault.

Conclusion: Statistics from Sweden reports that 13-16 % of all elderly have been victims to some kind of abuse. Even though there has been an increase in research concerning abuse against elderly in the last decades, challenges to identify and intervene against maltreated elderly remains. A large material was used for this study still very few cases of elder abuse was identified, part of this low number can be due to the inclusion criteria and more research is needed. Still there is not enough knowledge concerning elder abuse in Sweden and therefore medical staff face serious problems to recognize and treat these patients at an ED.

Next important step to improve the situation for this patient group would be to introduce a screening tool to identify more persons at risk and develop a follow-up program so that these patients are not left destitute.

Karin ERWANDER (Gothenburg, SWEDEN), Kjell IVARSSON
15:50 - 15:55 #18569 - SP054 Triage urgency and frailty as predictors of early mortality in older patients in the emergency department: a prospective follow-up study.
SP054 Triage urgency and frailty as predictors of early mortality in older patients in the emergency department: a prospective follow-up study.

Background
Adequate disease specific emergency department (ED) treatment begins with adequate triage to establish urgency and reduce early mortality. Triage in older patients can be challenging due to the presence of multimorbidity, atypical presentation of complaints or the presence of frailty. Our aim was to study the association between disease specific urgency and early mortality in older patients and to study whether the presence of frailty affects this association.

Methods
This was a secondary analysis of the observational multicentre Acutely Presenting Older Patient (APOP) study, in which ED patients aged ≥70 years were prospectively included. Patients were triaged using the Manchester Triage System (MTS) at presentation. Frailty screening was performed using the APOP-screener, which can be administered within 2 minutes at presentation. The primary outcome was 30-day mortality. We assessed whether prediction of mortality was more accurate when frailty was added to MTS by calculating Nagelkerke R² for both models.

Results
We included 2629 ED patients with a median age of 79 (IQR 74-84) years of whom 521 (20.0%) patients were frail according to the APOP screener. Patients were assigned as non-urgent (‘green’, N=717, 27.3%), urgent (‘yellow’, N=1534, 58.3%) and very urgent (‘orange’, N=378, 14.4%). In total 135 (5.1%) patients died within 30 days: 24 (3.3%) non-urgent patients, 84 (5.5%) urgent patients and 27 (7.1%) very urgent patients. Overall, the 30-day mortality rate was higher in frail patients compared to non-frail patients (11.7% vs. 3.4%, p<0.001). This difference was significant within all triage categories. The explained variance of the association between triage and 30-day mortality was higher when in addition to MTS alone (R² 0.009) patients were also screened with the APOP screener (combined R² 0.062).

Conclusion
Combining a frailty measure with the current triage tool improves prediction of early mortality in older ED patients. Adding frailty screening to the routine triage process may help deliver appropriate care to acutely ill older patients.

Laura BLOMAARD (Leiden, THE NETHERLANDS), Corianne SPEKSNIJDER, Jacinta LUCKE, Jelle DE GELDER, Sander ANTEN, Stephanie SCHUIT, Jacobijn GUSSEKLOO, Simon MOOIJAART, Bas DE GROOT
15:55 - 16:00 #18572 - SP055 Feasibility of screening with the acutely presenting older patient (APOP) screener in routine emergency department care: a feasibility study.
SP055 Feasibility of screening with the acutely presenting older patient (APOP) screener in routine emergency department care: a feasibility study.

Background
Frailty screening of older patients in the emergency department (ED) is rarely successfully implemented in routine care. The aim of this study was to evaluate feasibility of screening using the recently validated Acutely Presenting Older Patient (APOP) screener, which identifies older ED patients at highest risk of adverse outcomes within two minutes at presentation.

Methods
This two months’ prospective observational cohort study started after implementation of the APOP screener in ED procedures of the Leiden University Medical Center (LUMC). All consecutive patients aged ≥70 years presenting to the ED were included. The main outcome was adherence to screening by triage-nurses, operationalised by the screening rate. We identified determinants of screening omission by assessing patient-, disease- and organizational related factors. Next to this, feedback of triage-nurses on barriers and facilitators of screening adherence was collected with questionnaires.

Results
In total 986 older patients were included, of which 566 (57.4%) were screened. The screening rate was stable over time. A younger age (OR 1.03 (95%CI 1.01-1.06), p=0.018), triage category “red” (OR 0.14 (95%CI 0.04-0.43), p=0.001) and crowding (>14 ED patients upon arrival) (OR 0.65 (95%CI 0.47-0.88), p=0.005) were independent determinants of screening omission. In line, the most important barriers for screening adherence according to triage-nurses were patient- (“patient was too ill”) and organizational factors (“ED was too busy”).

Conclusion
Screening older patients in routine ED care with the APOP screener was feasible. Since adherence to screening was related to patient and organizational factors, attention for these both aspects could improve implementation.

Laura BLOMAARD (Leiden, THE NETHERLANDS), Shanti BOLT, Jacinta LUCKE, Jelle DE GELDER, Anja BOOIJEN, Jacobijn GUSSEKLOO, Simon MOOIJAART, Bas DE GROOT
16:00 - 16:05 #18739 - SP056 Quality of life among acutely admitted elderly with and without homecare - A cross sectional study.
SP056 Quality of life among acutely admitted elderly with and without homecare - A cross sectional study.

Introduction

In Denmark (2017) out of 600.000 yearly hospital admissions of elderly ≥ 65 year, 77.5% were acute. Acute admitted elderly who are dependent on homecare may be especially challenged. Nuanced knowledge about their quality of life (QoL) is limited. The aim of this study is to investigate the difference in ratings and definition of QoL between acutely admitted patients ≥ 65 years, with and without homecare.

Methods

A cross sectional study is in progress at three Danish emergency departments (ED). Acutely admitted cognitively well-functioning patients ≥ 65 are invited from August 2018 and interviewed during their admission. The primary outcome is QoL measured by the questionnaire Schedule for the Evaluation of Individual Quality of Life – Direct Weighting (SEIQoL-DW) (scale 0-100). In order to determine their QoL, the patients select and rate the five most important areas of their QoL. In addition, length of stay and hours of received homecare per week are collected from their medical records.

Linear regression analyses will be used to test the associations between homecare (≥ 2 hours per week) and QoL. The most important areas selected and defined by the patients will be described qualitatively. The areas will be condensed into themes to find the participants overall definition of QoL. Difference in QoL between the groups will be tested by un-paired t-test.

A sample size calculation for two-sample means test, level of significance 95%, power 80% and with 10 percent difference in QoL score between the two groups showed that 406 participants is required.

Results

At present, 297 participants are included in the study and 28% of them receive homecare. Mean age is 76 years (min 65 – max 96), 46% are male and 42% of the participants are living alone. Median length of stay is 41 hours (Interquartile range (IQR): 22 – 86) and 63% of the participants are discharged from the ED. Median QoL score is 81.9 (IQR: 70.0 - 90.3) and areas of importance for the patients QoL so far are; family, friends, neighbours, freedom, activities, and health. The time required to complete SEIQoL-DW is 30 min (IQR: 27-35). The inclusion is expected to be completed in June 2019 and analyses on the full data set will be ready in October.

Conclusion

This study is ongoing. The authors expect that a patient perspective on QoL can provide nuanced knowledge on QoL among acutely admitted patients and to be able to detect association between QoL and dependence on homecare.  Aspects that define individual QoL among patients receiving homecare can be used to develop a guide about the most important priorities and adjustments in nursing care and discharge procedures regarding this fragile population.

Mette ELKJÆR (Aabenraa, DENMARK), Jette PRIMDAHL , Christian BACKER MOGENSEN, Mikkel BRABRAND , Bibi GRAM

Monday 14 October

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EPOSTER 3.5
15:45 - 16:05

ePoster 3.5 - Short Oral Presentation - Screen 5

15:45 - 15:50 #18422 - SP057 Non-urgent calls to the ambulance service: why do people call and what advice they are given?
SP057 Non-urgent calls to the ambulance service: why do people call and what advice they are given?

Background

In England, approximately 10% of patients who contact the ambulance service are triaged as having low urgency health problems which may not necessitate an ambulance response. These patients often receive clinical advice by telephone instead of an ambulance being sent. This has potential to reduce pressure on ambulance service resources and, in doing so, free up ambulance responses for more urgent cases. A recent study  used linked ambulance and other health event data to identify what happens to patients following the decision to give clinical telephone advice and this identified low rates of hospital admissions (2.5% -10.5%) and deaths (0.006%-0.24%) (within 3 days of receiving ambulance telephone advice). This analysis builds on this research to identify why these patients called the ambulance service and what clinical advice they received. 

Methods

Using the same patient population as the previous study (n=2521 patients who received clinical telephone advice from the ambulance service and whose data was linked to other health event data through the Prehospital Outcomes for Evidence Based Evaluation, PhOEBE study), we obtained additional Advanced Medical Priority Dispatch System (AMPDS) about reason for call (‘what’s the problem’) and clinical telephone advice data from the Telephone Advice Service (TAS). For data linkage purposes, this patient population all had other experiences of contacting the ambulance service. AMPDS and TAS data was linked to the PhOEBE study data using Computer Aided Dispatch (CAD) number (a unique ID for each patient) and date and time was used for verification of the linkage. The additional AMPDS and TAS data obtained for this study was text data, therefore a thematic coding framework was developed to code and categorise the data in order to identify reason for call and clinical advice given.

Results

All newly obtained data was successfully linked to the PhOEBE study data. Using the coding framework, we found that for this low urgency patient population, the most common reason for calling the ambulance service was pain (39.35%). Other reasons included diarrhea/vomiting (11.42%), minor health problems (e.g. wound dressing problems, nosebleeds, catheter issues) (9.12%), mental health, alcohol/drugs or crisis problems (8.45%) and difficulty in breathing (8.57%). A paramedic or nurse advised patients what to do next. Most patients were advised to seek in-hours GP care (27.6%) or to self-care (21.4%). 17.9% were advised to seek out-of-hours urgent care and 9.3% were advised to attend ED.

Conclusion

Some callers seek emergency care for low urgency health problems and ambulance services are developing ways to respond to these calls in a more cost efficient way.  Given that most patients were advised primary care or self-care following ambulance telephone advice, and that low subsequent event rates were identified in the previous study, this indicates that telephone advice for low urgency ambulance service callers is largely safe, and has the potential to ensure resources are available for patients with more urgent health problems. Further work is required to understand whether telephone advice is acceptable to patients.

Joanne COSTER (Sheffield, UK), Jon NICHOLL , Alicia O'CATHAIN
15:50 - 15:55 #18768 - SP058 The ideal urgent and emergency care system: a qualitative study of public perspectives.
SP058 The ideal urgent and emergency care system: a qualitative study of public perspectives.

Background

It is well documented that large numbers of people seek help for their healthcare needs in secondary emergency care services, such as Emergency Departments (ED) and the ambulance service, when they could have been treated much closer to home. This is putting increased strain on already overstretched and costly urgent and emergency care (UEC) services, which is unsustainable in the long term.

There is an increasing body of literature that has focused on asking patients how they use UEC services with the intention of identifying the reasons for this behaviour. Other studies have described factors that appear to influence patient satisfaction with UEC services. Whilst informative, these studies do not take into consideration what it is that patients actually want from the UEC system. As a result, services are often implemented without consulting the people who will directly benefit from them. The aim of our study was to discuss patient experiences of accessing UEC services and then identify from the patient perspective, what an ideal UEC system would look like.

Methods

Members of the public in a large English city (population >720,000) were invited to participate in focus groups using a purposeful sampling technique, between September and December 2018. To be eligible to participate, participants must have been in contact with a UEC service (ambulance, walk-in centre, ED, Minor Injuries Unit, out-of-hours GP or NHS111) within the last 12 months and stratified into at least one of the following cohorts: (1) working age (

Results

Four workshops were undertaken with 30 members of the public. Respondents were diverse representing each of the four cohorts. The ideas generated by participants centred around three themes: (1) greater communication from health professionals; (2) linked medical records to ensure consistency of care across the UEC system; (3) a more simplified UEC system which is easier to navigate and access. These ideas were directly influenced by participants past experiences of accessing UEC services, whereby they attempted to identify solutions to the problems they commonly encounter.

Conclusion

This is the first study documenting members of the public’s views of what their ideal UEC system would look like. Participants agreed that services need to work more closely together to provide a more efficient and joined up service. This requires greater communication between health professionals, particularly in relation to discharging patients back into community services. Centralised medical records accessible to all services should be seen as priority. This will ensure continuity of care for patients across the whole healthcare system. Additionally, clarity around what UEC services are available locally, what health conditions are appropriate for these and how people can refer into these services are also important.

Maxine KUCZAWSKI (Sheffield, UK), Suzanne ABLARD, Suzanne MASON
15:55 - 16:00 #18795 - SP059 International Commission for Mountain Emergency Medicine (ICAR Medcom) consensus guidelines for on-site management and transport of patients in canyoning incidents.
SP059 International Commission for Mountain Emergency Medicine (ICAR Medcom) consensus guidelines for on-site management and transport of patients in canyoning incidents.

Background: Canyoning is a recreational activity that has increased in popularity in the last decade in Europe and North America, resulting in up to 40% of the total search and rescue (SAR) costs in some geographic locations. SAR operations in canyons are frequently necessary when companion-rescue fails and often require special considerations because of remoteness, difficult terrain and limited communication. Specially trained and equipped SAR teams have been established, but there is no international consensus pertaining to minimum requirement levels of medical training and technical training for canyoning rescue.

Objective: The International Commission for Mountain Emergency Medicine (ICAR Medcom) convened an expert panel to develop recommendations for on-site management and transport of patients in canyoning incidents.

Methods: The International Commission for Mountain Emergency Medicine (ICAR Medcom) convened an expert panel to develop evidence-based recommendations for on-site management and transport of patients in canyoning incidents. After generating a set of topics, an extensive literature search was done using electronic databases and manual searching. Recommendations are graded on the basis of quality of supporting evidence according to the American College of Chest Physicians (ACPP) classification scheme.

Results: From a total of 32 citations that were received, 12 peer-reviewed articles, 6 peer-reviewed abstracts, 6 medical theses and one epidemiological report were found to be relevant and were subjected to full review. Health care providers operating in canyon SAR should be prepared to manage prehospital trauma care and conditions such as accidental hypothermia, drowning and heat-related illnesses. Health care providers must have specific technical skills for ground and air rescue operations, and the ability to work safely in canyon environments and to operate on the basis of therapeutic options that may be limited. Canyon SAR teams should train for the use of special devices for evacuation and in-water and technical (winch and high-angle maneuvers) transport.

Conclusion: The current evidence-based recommendations for prevention and management of canyoning incidents focus on its unique combination of remoteness, water-exposure and specific technical mountain skills. Further research should be directed at evaluating the efficacy of medical interventions in canyon environments.

Giacomo STRAPAZZON (Bolzano, ITALY), Oliver REISTEN, Fabien ARGENONE , Ken ZAFREN, Greg ZEN-RUFFINEN , Gordon L. LARSEN , Inigo SOTERAS
16:00 - 16:05 #18861 - SP060 Increasing use of EMS by the elderly and patients with non-specific diagnoses.
SP060 Increasing use of EMS by the elderly and patients with non-specific diagnoses.

Background

The use of emergency ambulances has been increasing in recent years. Emergency medical services (EMS) and EMS research primarily focus on time-critical conditions such as cardiac arrest, respiratory failure, myocardial infarction, stroke and severe trauma – the “first hour quintet”. Little is known about the entire EMS patient population in terms of age profiles, the diagnostic pattern and changes over time.

 

Aim

We aimed to investigate changes in age profiles and hospital diagnoses among EMS patients from 2007 to 2018. 

 

Methods

Population-based historic cohort study including EMS patients in the North Denmark Region during 2007, 2014 and 2018. Ambulance data was retrieved from prehospital electronic medical record and data on hospital diagnoses according to International Classification of Diseases (ICD-10) from the regional patient administrative system. We performed descriptive statistics to report the results as frequencies and percentages.

 

Results

The overall number of EMS patients with hospital contacts increased: 14 551 in 2007, 23 928 in 2014 and 26 560 in 2018, corresponding to an 80% increase. Especially the older age groups (65+) increased in number and fraction from 4 781/32.9% in 2007, to 9 995/41.8% in 2014 and finally 11 980/45.1% in 2018.  Likewise, from 2007 to 2018, non-specific diagnoses increased from 3 993/27% to 10 183/39%. Injuries increased in numbers from 4 999 to 6 537, but decreased in fraction from 34 % to 25 %. Cardio-vascular and respiratory diseases increased in numbers (1 450 to 3 088 and 883 to 2 098) but fractions remained largely unchanged. Finally, psychiatric disease/substance abuse decreased in fraction 962/7% to 1 053/4%.

 

Discussion and conclusions

The number of EMS patients with subsequent hospital contact almost doubled during the years and number of older patients increased with a factor 2.5. The non-specific diagnoses dominated the pattern with around 40%, while cardiovascular diagnoses constituted only 10-12%. Although time-critical conditions are of great importance in EMS, an entirely different group of patients – the non-specific diagnoses, dominates the population. In addition, more awareness should be directed towards the increasing number of patients with increasing age. In future research, we plan to investigate to which extent demographic changes can explain the increasing age of the EMS population.

Morten BREINHOLT SØVSØ, Torben Anders KLØJGAARD, Tim Alex LINDSKOU (Aalborg, DENMARK), Kenneth LÜBCKE, Erika FRISCHKNECHT CHRISTENSEN
Tuesday 15 October
10:45

Tuesday 15 October

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EPOSTER 4.1
10:45 - 11:05

ePoster 4.1 - Short Oral Presentation - Screen 1

10:50 - 10:55 #18171 - SP062 Putting out the fire: extinguishing burnout.
SP062 Putting out the fire: extinguishing burnout.

Background 

The 2018 national training survey carried out by the General Medical Council (GMC) in the UK demonstrated that one in four of 51,956 trainees and one in five of 19,193 trainers had feelings of burnout.  Burnout harbours increased risk of suicide, mental health issues, cardiovascular disease, relationship problems and substance abuse.  It can lead to detrimental patient care with a recent meta-analysis showing 2-fold increased odds for poorer patient safety and satisfaction along with increased unprofessional behaviour.  In this cross-sectional study, we sought to examine whether an innovative clinical fellow program in the emergency department (ED) at the Royal Sussex County Hospital (RSCH) has been beneficial to clinicians wellbeing.  Our aim is to demonstrate whether decreased levels of burnout are associated with the ED clinical fellow program. 

Methods 

The Copenhagen Burnout Inventory (CBI) was used and disseminated via email.  Scores of less than 25, 25 to 49, and 50 or more were categorized as low, intermediate, and high burnout.  All answers were anonymous.  The questionnaire was open between July and August 2018.  It was sent to doctors of four different specialities (orthopaedics, acute medicine, emergency medicine and general surgery) and of varying grades (FY1 level to consultant).  

 

Results  

There were 128 respondents with a response rate of 77% (n=165): emergency medicine (n= 51, 39.8%), acute medicine (n=36, 28.1%), orthopaedics (n=27, 21.1%), general surgery (n=14, 10.9%).  There were 25 consultants (19.5 %), 46 registrars (40 %) and 71 junior doctors (55.5 %).  The general surgery doctors had the highest total burnout scores (50.00+/-28.32) followed by emergency medicine (46.47+/-23.64), acute medicine (46.13+/-24.24), and orthopaedics (40.20+/-25.49). Junior doctors had the highest burnout scores (53.42+/-24.07), followed by consultants (44.48+/-24.12) and registrars (39.54 +/-21.86).  

ED clinical fellows had lower average burnout scores (38.95 +/- 24.84) than the rest of the respondents (45.43 +/-12.68), which was approaching significance (p=0.06).  When compared to all other respondents within ED (49.6 +/- 9.54), clinical fellows did have statistically significantly lower average burnout scores (p=0.002) 

 

Discussions and Conclusions  

Our surgical colleagues had the highest burnout scores.  There is ample data to suggest that it is emergency medicine clinicians that have amongst the highest levels of burnout and we presumed this would be the outcome. 

We can see a general trend of increasing burnout scores with decreasing seniority and this is consistent with other studies comparing different grades of clinicians.   

ED clinical fellows had lower burnout scores compared to all the other specialities and to the rest of the cohort within ED.  The ED clinical fellows have a different job plan and this could be the contributory factor to their improved well-being.  Their annualised rota, part time clinical work, simplified shift patterns and extracurricular projects along with a full workforce, 24 hour consultant cover and self-rostering for registrars appear to have combined into the perfect storm to positively affect clinician wellbeing.  More departments should be taking note of these change to try and mitigate against the devastating impact that burnout will have on the workforce and the individual it affects.  

Catherine BERNARD (Brighton, UK), Sarah TYLER, Ben CAESAR, Ahmed BARAKAT, Donna BUTLER
10:55 - 11:00 #18244 - SP063 Outcomes of intra-arterial thrombectomy in acute ischemic stroke: direct transport versus transfer from another hospital.
SP063 Outcomes of intra-arterial thrombectomy in acute ischemic stroke: direct transport versus transfer from another hospital.

Background

There had recently been a surge in published studies documenting the effectiveness of mechanical intra-arterial thrombectomy (IA) as a treatment for patients with acute ischemia strokes(AIS).This study aim to identify whether there is benefit to direct transport patients with AIS to hospital that be able to provide IA

Methods

We retrospectively recruited all patients receiving IA as the treatment for AIS from January 2016 to December 2018. Neurologist was consulted for all AIS patients . IA criteria including 1. within 8 hours of the time last known to be well for anterior circulation stroke; within 24 hours of the time last known to be well for posterior circulation stroke,2. Computed tomography angiography demonstrated proximal large vessel occlusion,3. National Institutes of Health Stroke Scale (NIHSS) ≧8 or ≦30.Patients were divided into two groups: direct transport to our hospital or transfer from another hospital.The primary outcome of this study was the time since symptoms onset until the time of receiving IA. Our secondary outcomes were NIHSS 24 hours posttreatment , on discharge and Modified Rankin Scale (mRS) on discharge, 1 month follow up, 3 month follow up.

Results

In total, 254 patients were enrolled into this study after excluded those who met the aforementioned exclusion criteria. The majority was males (59.84%) and the transfer group had 148 (0.58) cases. There was no statistically significant in time between symptoms onset to IA between two groups. In the T- test analysis , there was statistically significant difference in NIHSS 24 posttreatment between these two groups(p=0.002).However, there were no significant difference in NIHSS on discharge in t- test analysis ,or mRS on discharge or further follow-up in chi-square test analysis .

Conclusions

In this retrospective study comprising 254 AIS patients receiving IA, we found there is no difference in NIHSS or mRS between those transferred from another hospital and those who visited our hospital directly.

Yenju CHEN (taichung, TAIWAN), Daming CHEN, Chihyu CHEN, Tai-Yi HSU, Weikung CHEN
11:00 - 11:05 #19347 - SP064 Levetiracetam :Worth a use in Status Epilepticus.
SP064 Levetiracetam :Worth a use in Status Epilepticus.

Case Vignette:

During one of the busy shifts in ED in a DGH, I received a pre alert regarding a 56 years old female who was having continuous seizures for past 30 minutes (SE) and had already received 10mg of P/R diazepam by the paramedics. On arrival she was still having generalized convulsive seizures and I quickly administered I /V LOR 4mg. She continued to seize despite of that and the decision was to give I/V PHT as per the guidelines. Her vital signs showed a SBP of 80mmhg and she had a background of AF.Despite knowing the fact that the most common side effects of PHT are hypotension and arrhythmias, we went ahead and gave the PHT to control the seizures, as per the guidelines. Patient became more hypotensive after that and needed inotropic support. The seizure activity stopped but patient needed RSI and was admitted to ICU.

This raised a question that whether there was an alternative to PHT, which can be used as effectively but more safely. On researching more, I came across LVT, which showed promising results in controlling the seizures and hence prompted me to review the evidence in its use in SE.

Three part Question:

In {adult patients with Status Epilepticus}, is {Levetiracetam a safe and effective second line anti-convulsant compared to Phenytoin}, in {terminating seizures}?

Literature Search:

Using the Athens interface (www.library.nhs.uk), I did a comprehensive literature search of MEDLINE (1946 to date), EMBASE (1980 to present), and CINAHL (1981 to present) databases, searching titles and abstracts, as well as index linking.The abstracts of the 247 unique papers were reviewed to ascertain if they answered the question, using the inclusion and exclusion criteria,this found 8 unique papers.There were 3 retrospective, 2 prospective, one systematic review,one meta analysis and one critical review.

These 8 papers have been critically appraised and reviewed. Levels of evidence have been graded as per the ‘Strengthening the Reporting of Observational studies in Epidemiology’ (STROBE) checklist (scored out of 22, Appendix 1), as well as the Scottish Intercollegiate Guidelines Network12 (SIGN - Appendix 2). 

Outcome and Conclusion:

All the studies had a clear objective, sound methodology and they showed promising results in terms of the outcome. The efficacy of LVT is comparable to PHT with less serious side effects, although the results were not statistically significant, p value >0.001.All the retrospective case series reported an efficacy between 61.8% to 94% for the use of LVT in SE,especially when used in elderly population with comorbidities,as supported by Z Yasiry9 et al, in their meta-analysis.

There is strong evidence to suggest that LVT is a safe and effective drug for its use in SE.The I/V formulation is still not licensed for use in SE, but the accumulating evidence in the literature suggests that the efficacy of LVT is comparable or even better than PHT.The use should be individualised as per the clinical need.

ESSTT30 and ECLIPSE29, are two promising RCT going on at present to compare the safety and efficacy of LVT.

Saurav BHARDWAJ (Birmingham, UK), Amit JAISWAL, Virupaksha SADHUNUVAR

Tuesday 15 October

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EPOSTER 4.2
10:45 - 11:05

ePoster 4.2 - Short Oral Presentation - Screen 2

10:45 - 10:50 #18228 - SP065 Decompressive craniectomy may not be effective for traumatic brain injury; A Nation-wide propensity score matching cohort study in Japan.
SP065 Decompressive craniectomy may not be effective for traumatic brain injury; A Nation-wide propensity score matching cohort study in Japan.

Background: Cerebral edema in traumatic brain injury can lead to cerebral herniation and result in disability or death. Decompressive craniectomy (DC) has been performed for the purpose of relieving elevated intracranial pressure with outcome improvement in severe TBI patients. However, there was little evidence whether DC was effective for outcome of TBI patients. We assessed the relationship between decompressive craniectomy for patients with severe traumatic brain injury and the prognosis using nation-wide hospital-based trauma registry in Japan.

Methods: Using Japanese Trauma Data Bank, we included severe traumatic brain injury patients whose head AIS scores were 3 and over and registered from 2004 to 2017 in this study. Multivariable logistic regression analysis and conditional logistic regression analysis were used to assess the association between decompressive craniectomy and the prognosis of traumatic brain injury patients after one-to-one propensity score matching for DC versus non-DC. The primary outcome was dead at hospital discharge.

Results: Among 69411 eligible patients with severe traumatic brain injury, 1523 patients (2.2%) received DC and 67888 patients (97.8%) did not receive DC. In the univariate analysis, the proportion of dead at discharge was higher in the DC group than the non-DC group (36.5% [556/1523] vs. 14.5% [9828/67888]). In the multivariate analysis, the DC group showed a more favorable survival outcome than the non-DC group (adjusted OR 0.294, 95% CI; 0.265-0.327). However, in the propensity-matched cohort, the DC group did not show a more favorable survival outcome than the non-DC group (68.7% [1045/1522] vs. 63.5% [967/1522], adjusted OR 0.787, 95% CI; 0.675-0.919).

Conclusion: Decompressive craniectomy may not be effective for patients with severe traumatic brain injury.

Yumi MITSUYAMA (Osaka, JAPAN), Yusuke KATAYAMA, Tetsuhisa KITAMURA, Nakagawa YUKO , Takeshi SHIMAZU
10:50 - 10:55 #18250 - SP066 Accuracy of TRISS and RISC II in predicting 30-day mortality in major trauma patients in Hong Kong: Retrospective cohort study.
SP066 Accuracy of TRISS and RISC II in predicting 30-day mortality in major trauma patients in Hong Kong: Retrospective cohort study.

Background:

Hong Kong has established an inclusive trauma system since the early 2000, and local trauma registries have been using TRISS methodology for audit and benchmarking purposes since its establishment. TraumaRegister DGU in Germany devised its own probability of survival model using data from its 900 trauma centres. RISC II was demonstrated to be superior to TRISS in Germany, and includes pre-trauma ASA, pupil size and reactivity, pre-hospital CPR and laboratory results including INR, base deficit and haemoglobin on top of those parameters used in TRISS. The aim is to compare the predictive ability of the probability of survival calculated using TRISS and RISC II for major trauma patients in Hong Kong.

 

Methods:

This was a retrospective cohort study using data from all five trauma centres in Hong Kong. Adult major trauma patients (ISS>15) from January 2013 to December 2015 were extracted from the five respective trauma registries. Parameters for TRISS was collected prospectively, and those extra data points in the RISC II scores were retrieved retrospectively. The primary outcome was the area under the ROC curve for TRISS and RISC II using the expected and observed 30-day mortality. Probabilities of survival (Ps) were derived by TRISS with MTOS coefficients and RISC II methodology. The Hosmer-Lemeshow goodness of fit test was used to test for the calibration of the model. Subgroups analyses investigated the performance of TRISS and RISC II for the mechanism of injury and age>80. Ethics approval has been obtained from the local review board.

 

Results:

1864 patients were recruited during the study period. 67.2% was male and the median age was 60 years old. The median ISS was 24, with 40% of patients with ISS over 25. Low fall was the most common mechanism of injury, with head and neck being the most commonly injured body region. The 30-day mortality was 22.4%. The expected mortality was 20.0% using TRISS and 19.7% from RISC II. The AUC was 84.8% (CI 82.7 to 86.9) and HL test 63.2 (p<0.001) for TRISS. RISC II yielded a superior AUC of 89.6% (CI 88.1 to 91.2) and HL test of 78.9 (p<0.001).

Subgroup analyses showed that both score performed worse for ISS 25 or above (AUC: TRISS 80.4%, RISC II 87.7%), age 80 or above (AUC: TRISS 80.6%, RISC II 82.9%), low falls (<2m) (AUC: TRISS 81.7%, RISC II 85.5%), and significant head or neck injury (AIS 3 or above) (AUC: TRISS 83.1%, RISC II 87.7%). RISC II had performed significantly better than TRISS for all subgroups, except in age 80 or above and low falls.

Conclusion:

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult trauma patients with ISS >15. RISC II also significantly better than TRISS in all subgroups, except in age 80 or above and low falls. These points should be taken note when performing future audit or benchmarking exercises.

Kevin Kc HUNG (Hong Kong, CHINA), Cosmos LAI, Janice Hh YEUNG, Marc MAEGELE, Colin A GRAHAM
10:55 - 11:00 #18899 - SP067 A retrospective analysis of tranexamic acid administration in the major trauma population conveyed to the Queen Elizabeth University Hospital, Glasgow.
SP067 A retrospective analysis of tranexamic acid administration in the major trauma population conveyed to the Queen Elizabeth University Hospital, Glasgow.

Background

NICE Major Trauma Guidelines, introduced in February 2016, support the administration of 1g bolus of tranexamic acid (TXA) within 3-hours in patients with major trauma and active or suspected bleeding, followed by a further 1g over 8-hours. This recommendation, based on evidence from the CRASH-2 trial, illustrated a significant time-dependent mortality benefit. The Queen Elizabeth University Hospital (QEUH), Glasgow, receives the majority of the West of Scotland’s major trauma and was identified as a site where appropriate administration of TXA could yield most benefit.

Aims

To assess those patients admitted to the QEUH, who were administered 1g TXA and whether this was within 3 hours of injury as per NICE guidelines. The second aim was to identify how many of these patients go on to have a second dose of TXA administered as an infusion over 8-hours when clinically indicated.

Methods

After review of supporting literature, a retrospective cohort study was designed. Study population included all trauma patients who were admitted to the QEUH and received TXA between 01/11/2017-28/08/2018.  Data concerning demographics and TXA administration were collected electronically from the trauma registry (eSTAG) and verified using electronic clinical records. Twenty-five secondary transfers were excluded as well as ten patients with insufficient data. Data is presented as a mean (standard deviation) or as a median (interquartile range) as appropriate.

Results

One hundred and fourteen patients were identified by eSTAG as having received TXA and were admitted to the QEUH. Of these, 79 patients were analysed and 35 were excluded. Seventy-three (92.4%) patients received their initial dose of TXA within 3 hours and 6 (7.6%) did not. Median time to first dose was 70 minutes (44-110 minutes). Only 1 (0.79%) patient received an incorrect dose of 200mg, all others received 1g.

Of the 79 patients, 9 received a second dose of TXA, 3 as an infusion. All second doses were given within 24 hours of the initial TXA dose, median time 115 minutes (65-162.5). One patient received a second dose of 800mg, the rest received 1g.

Discussion and Recommendations

In spite of current trial data demonstrating a significant reduction in mortality following use of TXA in major trauma with suspected bleeding, this study indicates that this has not yet been incorporated into clinical practice. This is especially true regarding administration of a second dose with only 9 patients receiving this dose and with none of these following the protocol outlined in the literature. One reason secondary dosing might be so low is that it may not be indicated if patients were found not to be actively bleeding. Not being able to verify those that had a clinical indication and those that did not is a limitation of the study.

With current evidence supporting administration of a secondary TXA dose further efforts should be made to encourage this through education of both pre-hospital and hospital practitioners. It should also be highlighted that first dosing of TXA after 3 hours has been associated with higher rates of mortality and should therefore be avoided.

Gage WILLOX, Chase SCHULTZ-SWARTHFIGURE (Glasgow, UK), Hannah SMITH, Malcolm GORDON
11:00 - 11:05 #18992 - SP068 Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities.
SP068 Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities.

Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities. Authors: Saima Salman, Syed Ghazanfar Saleem, Qurat ul Ain Sheikh3, Kaniz Farwa Haider4, Megan Rybarczyk5, Zayed Yasin6, Lubna Samad7, Anna Q Yaffee8. CONFLICT OF INTEREST: No conflict of interest FUNDING: No external funding was sought for this research work ABSTRACT: Introduction: Structured trauma care has been proven in literature to improve patient outcome. Many organized systems are established across the globe to familiarize and train Emergency Physicians with basic and advance trauma care. The need is more pronounced in low and middle income countries (LMICs) where limited resources and poorly structured health care systems add to the challenges of trauma care with increase in morbidity and mortality. Characterization of epidemiology of trauma helps in identification of risk factors, injury severity and outcomes and establishes the baseline upon which interventions can be structured. Objective: To characterize the epidemiology of trauma patients presenting to the emergency department (ED) at The Indus Hospital (TIH) in Karachi, Pakistan including demographics, presenting Injury Severity Score (ISS), interventions and disposition. Methodology: One year Retrospective chart review of all poly-trauma patients older than 14 years from July 2017 to June 2018 presenting to TIH ED was conducted. Results: Out of 972 trauma patients presenting to TIH ED, 663 (68.2%) were males and 309 (31.7%) were females. Road traffic accidents were the most common mode of presentation with 766 patients (78.8%) followed by 121 falls (12.7%). Injury Severity score (ISS) was calculated upon arrival and 528 (54.3%) were found to be critically injured. All 365 discharged patients (100%) were moderately injured with scores of 9-15 and there was 100% mortality of the maximally injured nine patients with scores of 75. However, only 3.4% of these patients received a Focused Assessment Sonography in Trauma (FAST) ultrasound and none received further helical imaging of chest or abdomen. 90% received intravenous fluids but only 3.4% received a blood transfusion. Industrial trauma (p value 0.01) and falls (p value 0.007) were more common in men whereas burn victims were mostly women (p value 0.0001).  CONCLUSION: Given the unique position of TIH in terms of public-private partnership and philanthropy, the characterization of trauma patients presenting to TIH has strengthened our belief that patient outcomes can be improved through structured approach to trauma patients within the golden hour of trauma management through better inter specialty collaboration and lean utilization of resources. By identifying the gaps within patient management it is our hope that through interventions for capacity building, we will have a positive impact on patient outcome, specifically survival to discharge and stabilization/ diagnostic procedures received. KEY WORDS: Pakistan, Injury, Trauma, Injury Severity Score (ISS), Low and middle income countries (LMIC)

Saima SALMAN (Karachi, PAKISTAN), Anna YAFFEE

Tuesday 15 October

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EPOSTER 4.3
10:45 - 11:05

ePoster 4.3 - Short Oral Presentation - Screen 3

10:45 - 10:50 #18058 - SP069 Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department.
SP069 Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department.

Objectives We sought to estimate the prevalence of patients with cancer presenting to the emergency department (ED) who are undergoing treatment with immune checkpoint blockade (ICB) therapy; report their chief complaints; describe and estimate the prevalence of immune-related adverse events (IRAEs).

Methods Four abstractors reviewed the medical records of patients with cancer treated with ICB who presented to an ED in Paris, France between January 2012 and June 2017. Chief complaints, underlying malignancy and ICB characteristics, and the final diagnoses according to the emergency physician were recorded. Abstractors noted if an emergency physician identified that a patient was receiving an ICB and if the emergency physician considered the possibility of an IRAE. The gold standard as to whether an IRAE was the cause was the patients’ referring oncologist’s opinion that the ED symptoms were attributed to ICB and IRAE according to post-ED medical records. Descriptive statistics were reported.

Results Among the 409 patients treated with ICB at our institution, 139 presented to the ED. Chief complaints were fatigue (25.2%), fever (23%), vomiting (13.7%), diarrhoea (13.7%), dyspnoea (12.2%), abdominal pain (11.5%), confusion (8.6%) and headache (7.9%). Symptoms were due to IRAEs in 20 (14.4%) cases. The most frequent IRAEs were colitis (40%), endocrine toxicity (30%), hepatitis (25%) and pulmonary toxicity (5%). Patients with IRAEs compared with those without them more frequently had melanoma; had received more distinct courses of ICB treatment, an increased number of ICB medications and ICB cycles; and had a shorter time course since the last infusion of ICB. Emergency physicians considered the possibility of an IRAE in 24 (17.3%) of cases and diagnosed IRAE in 10 (50%) of those with later confirmed IRAE. IRAE was more likely to be missed when the referring oncologist was not contacted or when the patient had respiratory symptoms, fatigue or fever.

Conclusions ICB exposes patients to potentially severe IRAEs. Emergency physicians must identify patients treated with ICB and consider their toxicity when patients present to the ED with symptoms compatible with IRAEs.

Olivier PEYRONY (Paris), Yoann TIEGHEM, Jessica FRANCHITTI, Sami ELLOUZE, Ivonne MORRA, Isabelle MADELAINE-CHAMBRIN, Remi FLICOTEAUX, Barouyr BAROUDJIAN, Elie AZOULAY, Sylvie CHEVRET, Jean-Paul FONTAINE
10:50 - 10:55 #18346 - SP070 High-fidelity simulation versus low-fidelity simulation training for physicians’ cardiopulmonary resuscitation training: A systematic review and meta-analysis.
SP070 High-fidelity simulation versus low-fidelity simulation training for physicians’ cardiopulmonary resuscitation training: A systematic review and meta-analysis.

BackgroundHigh –fidelity resuscitation training is near to become the gold standard for training physicians on cardiopulmonary resuscitation techniques. Nevertheless, its effectiveness remains unknown.

ObjectiveThe objective of this study is to identify and synthesise the best available evidence for the effectiveness of high versus low fidelity simulation in physicians’ resuscitation training.

Data source-A systematic search of Pubmed and Embase was conducted considering the period from 1stJanuary 2008 to 31stDecember 2017.

Study selection-The research manuscripts evaluating High-fidelity simulation compared with low-fidelity in the training of physicians for CPR were considered for analysis.

Data extraction-Outcomes including written tests results, megacode scoring and other cardiopulmonary resuscitation (CPR) performance assessments were evaluated. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome. A fixed effect model was used, assuming standard mean as the effect measure.

Results-545 papers were eligible from the literature search and 17 were included in the analysis (16 RCT’s and one paired cohort study). Meta-analysis of skills performance evaluationusing megacode scoring evidenced a moderate benefit for High-fidelity simulation training when compared with low fidelity programs [SMD 0.54; 95% CI −0.36 to 0.73]. Similarly, written test results were better for High-fidelity simulation learners than for low fidelity simulation trainees [SMD 0.47; 95% CI 0.21 to 0.73]. Time to first compression favored adding some experimental intervention to High-fidelity simulation instead of High-fidelity alone [SMD 0.53; 95% CI 0.39 to 0.68]. 

Conclusion-The training of physicians on CPR with the use of High-fidelity simulation programs results in best technical and non-technical skills performances and increases theoretical knowledge.

Claudia FEBRA (Lisboa, PORTUGAL), Sandra PAIS, Ana MACEDO
10:55 - 11:00 #19054 - SP071 Anaphylaxis in an emergency department: Epidemiology, clinical features and management.
SP071 Anaphylaxis in an emergency department: Epidemiology, clinical features and management.

Background:

The rate of occurrence of anaphylaxis is increasing in the Emergency Department (ED).

Understanding potential triggers and patient-specific risk factors for severity and fatality is the key to performing appropriate risk assessment in those who have previously experienced an acute anaphylactic episode.

Objective:  

To describe the epidemiology, clinical features, management and outcome of patients with anaphylaxis in ED.

Methods:

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

Results:

A total of 687 patients were included. The mean age was 40 ±15years. Sex ratio=0,74.A history of anaphylaxis was reported in 40 % of cases. Cutaneous features were present in 96% of patients. Respiratory, cardiovascular, gastrointestinal and neurologic features were found respectively in 27, 22, 16 and 2%. Causative agent was known in 84% of cases. Most common category of causes n (%): drugs 363 (52,8%), food 170(24,7%) and insects 37(5,4%). No causes were apparent in 16,2% of cases. An anaphylactic shock was recorded in 336 patients (49%). Five factors were identified to be predictive for anaphylactic shock occurrence: history of anaphylaxis, anaphylaxis induced by antibiotics, parenteral administration, neurologic features and time elapsed between symptoms onset and the first medical contact equal to one hour. Adrenaline was used in 42%of patients, intravenously in 16,2%,via a breathing mask in 177 patients (25,8%).Fluid resuscitation was given to 610patients(89%).409 patients (59,5%) received histamine H1 antagonist, 658 patients (95,8%) received corticosteroids. 86%  of patients were discharged directly from ED after a mean period of observation of 5 hours. Biphasic reactions were reported in 13 patients. There was no death cases registered. Patients with drugs anaphylaxis were all referred to the allergy clinic.

Conclusion :

Anaphylaxis requires prompt recognition and management to improve patient outcomes.

Raja FADHEL, Emna REZGUI, Ines CHERMITI, Syrine KESKES, Sawsen CHIBOUB, Monia NGACH, Sana TABIB (Ben Arous, TUNISIA), Sami SOUISSI, Hanen GHAZALI
11:00 - 11:05 #19380 - SP072 Clinical manifestations of cocaine exposure in the pediatric emergency department.
SP072 Clinical manifestations of cocaine exposure in the pediatric emergency department.

Background: In the last decades, substance abuse has been mostly steady, with the exception of a significant increase in cannabinoids and cocaine circulation. From a clinical point of view, emergency department (ED) clinicians may evaluate substance abusers for a wide variety of symptoms. While adults and adolescents usually come to the ED with well-known clinical manifestations, no studies have thoroughly investigated how passive cocaine exposure might reveal itself in younger children.

Objectives: The aim of the study was to investigate the prevalence and describe presenting complaints and clinical manifestations of unsuspected exposure to cocaine in children attending to the pediatric ED.

Methods: We performed a retrospective study of children below 16 years of age evaluated in the ED of a tertiary care Pediatric Hospital of Padua, Italy, in 2018. Children were included if they received urine or blood toxicology screenings, in absence of a clear history of cocaine exposure.

Results: 102 children under 16 years underwent toxicology screening after evaluation in our Pediatric ED, 13 children showed positivity of urine or blood screening. Of these, 12 had confirmation of cocaine exposure by second-level analyses. Three were evaluated for signs and symptoms compatible with a first episode of absence epilepsy [Odds Ratio (OR) of cocaine exposure in these patients = 14.7, 95% confidence interval (CI) 2.16-99.7, p<0.05]. Other signs such as first convulsive episodes [OR = 1.44, 95% CI 0.35-5.87], tachycardia [OR = 2.52, 95% CI 0.58-10.94] or irritability [OR = 2.04, 95% CI 0.61-6.9] showed no correlation with confirmed cocaine exposure. All 13 patients were hospitalized, nine (69%) resulted positive for other substances, the most frequent being cannabinoids. Ten patients had dysfunctional family dynamics that would mostly surface during hospitalization, and were not investigated in the ED history-taking.

Conclusion: With the increase in cocaine abuse among adults, the risk of transfer to children is also increasing. Unfortunately, no single sign and symptom can be used to accurately identify children who have been exposed to cocaine. Toxicology screens may be useful for children presenting to the ED with suspicion of absence epilepsy. Clinicians should consider cocaine exposure in infants and children presenting with non-specific signs and symptoms, seizures or movement disorders. Larger studies will be needed to develop a prediction model of cocaine exposure in childhood.

Lorenzo ZANETTO (Padova, ITALY), Federica DAL PIVA, Melissa ROSA-RIZZOTTO, Silvia BRESSAN, Masiero SUSANNA, Deborah SNIJDERS

Tuesday 15 October

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EPOSTER 4.4
10:45 - 11:05

ePoster 4.4- Short Oral Presentation - Screen 4

10:45 - 10:50 #17926 - SP073 A new risk assessment model for the stratification of the thromboembolism risk in medical patients.
SP073 A new risk assessment model for the stratification of the thromboembolism risk in medical patients.

BACKGROUND: In hospitalized medical patients, the venous thromboembolism (VTE) risk is notable. Nevertheless, the available assessment model (TPF) is generally underused. In this work, we propose an ex novo risk assessment model based on the elaboration of the clinical data exhibited by the VET patients. Differently from previous studies, the proposed approach does not exploit pre-established models, resulting in a more valid and easy-to-use score.
METHODS: We performed a double case-control observational study. For each case of VTE, we enrolled two consecutive patients without VTE of equal sex and age group.
RESULTS: We analyzed the data of 1215 patients, 409 with VTE and 806 case-control. 365 patients (30%) were in charge to the EM department, while 850 patients (70%) to the IM one. The VTE risk factors with more statistical significance (P<0.01) are: previous VTE, active cancer, known thrombophilic condition, immobilization, chronic venous insufficiency, hyperhomocysteinemia, central venous catheter, recent hospitalization. Obesity, recent surgery, family history of VTE, hormone therapy and treatment with drugs that stimulate hematopoiesis are resulted at intermediate statistical significance (P<0.05 but >0.01). A multiple logistic regression was used with robust standard errors and forward selection of the candidate variables using the Bayesian information criterion. A new score is developed, the “TEVere Score”, which shows a higher specificity and sensitivity (respectively 43.3 and 87.5, with accuracy 72.1) compared with the Padua, the Kuscer and the Chopard Score. TEVere Score also exhibits a greater predictive validity for thromboembolism risk (AUROC 0.7266; 95% CI: 0.71 to 0.73) than the Kuscer Score (AUROC 0.6891; 95% CI: 0.67 to 0.70) (P=0.0093).
CONCLUSIONS: The TEVere Score has proven to exhibit a higher accuracy than the other scores commonly used in clinical practice to stratify the thromboembolism risk.

Giovanni Maria VINCENTELLI, Sergio TIMPONE, Giuseppe MURDOLO (perugia, ITALY), Igino FUSCO MOFFA, Paolo Diego L'ANGIOCOLA, Francesco BORGOGNONI, Manuel MONTI
10:50 - 10:55 #18042 - SP074 High-sensitivity cardiac troponin T 30-day all-cause mortality in patients with acute heart failure. A propensity score-matching analysis based on the EAHFE registry. EAHFE-TROPICA 4 Study.
SP074 High-sensitivity cardiac troponin T 30-day all-cause mortality in patients with acute heart failure. A propensity score-matching analysis based on the EAHFE registry. EAHFE-TROPICA 4 Study.

Background: Acute heart failure (AHF) patients with high levels of troponin have a worse prognosis. High-sensitive troponin T (hs-TnT) has been used as a tool to stratify prognosis in many scales but always as a qualitative variable, not as a quantitative one.

Objectives: The main objective of this study is to determine a cut-off for hs-TnT with an elevated  negative predictive value (NPV) for 30-day all-cause mortality.

Methods: We analyzed the EAHFE registry, a prospective follow-up cohort of patients with AHF. A propensity score analysis of the optimal hs-TnT cut-off point was performed, previously determined by a receiver operating characteristic (ROC) curve analysis.

Results: Of the 13791 patients in the EAHFE cohort, we analyzed 3190 patients in whom hs-TnT determination was available. The area under the ROC curve for 30-day all-cause mortality was 0.70 (95%CI 0.68 to 0.71; p < 0.001) and established an optimal cut-off of hs-TnT of 35 ng/L. The sensitivity and specificity for this cut-off were 76.2 and 55.5%, respectively, with a NPV of 95.3%. Thirty-four variables showed differences based on the cut-off of 35 ng/L for hs-TnT and a propensity score was made with them. A greater mortality at 30 days was shown in patients with hs-TnT > 35 ng/L in the analysis of the population obtained with the propensity score, with a HR of 2.95 (CI95% 1.83 – 4.75; p < 0.001).

Conclusions: A hs-TnT value of 35 ng/L is an adequate cut-off point to evaluate 30-day all-cause mortality with a NPV of  95.3%

Alex ROSET (Barcelona, SPAIN), Marco CORDERO, Carles FERRÉ, Ferran LLOPIS, Ignasi BARDÉS, Javier JACOB
10:55 - 11:00 #18464 - SP075 Acute hemodynamic effects of digoxin in patients with congestive heart failure.
SP075 Acute hemodynamic effects of digoxin in patients with congestive heart failure.

 

Introduction:

Digoxin was the cornerstone of heart failure therapy for decades due to its positive inotropic and neuro-hormonal modulation properties until the change of paradigm in heart failure pathophysiology. Our study evaluates outcomes stratified by heart function status in patients with heart failure treated with digoxin.

Materials and methods:

This is a prospective randomized ,  double blind ,placebo controlled parallel group multicenter clinical trial  . We randomly assigned  patients with  heart failure to treatment with digoxin or placebo(median dose of digoxin  is 0.25 mg per day). The effects of each one on hemodynamic parameters : systolic time interval , cardiac output , left ventricular ejection fraction and BNP level were compared during a period of 48 hours , double –blind trial  ,performed at the emergency unit of Fattouma Bourguiba hospital in Monastir over a period of four  years( 2016-2017-2018-2019).We also aimed to compare the risk of mortality and  hospital stay time with digoxin use versus no digoxin in patients with heart failure. The diagnosis of heart failure was based on current or previous symptoms such as dyspnea, radiologic or echo graphic evidence of pulmonary congestion ,BNP level > 350 pg / ml or  NT proBNP > 1400 pg/ml.  Participants were excluded if they already received digoxin as a background treatment. Those who had a pacemaker or suffered from severe renal impairment (creatinine clearance of less than 30 ml/min) were also excluded.

Results :

We have been collecting during 2016,2017,2018 and 2019 ,  cases of patients with heart failure and only 438 of them have met eligibility criteria  : 104 of them have received digoxin while 229 of them did not.

In our study ,  both groups had comparable demographic characteristics .There was no significant difference between the two groups ,in terms of age , sex or NYHA functional classification .

The increase of cardiac output within two days : 11.35 % in the group treated with digoxin ,7.75 % in the other group (without significant difference).
The increase of the systolic ejection fraction : 7.39 % in the group treated with digoxin ,2 % in the other group. The difference between both results appear to be significant

Systolic time intervals: pre-ejection period  decreased by 12.67 % in the group treated with digoxin ,1.01 % in the other group (the difference was highly significant)

( p= 0.02). Left ventricle ejection time  increased by  0.82 % in the digoxin group , 0.2 % in the other group . The difference was estimated to amount to 0.037.

  ED length of stay in the digoxin group : 6.67 days , 10 days  in the placebo group . The difference between the two was significantly high (p = 0.019). Death rate in the hospital : 1 % in the digoxin group and 0 % in the other group . The difference was not significant (p=0.78 ).

 Conclusion In patients with acute heart failure  , short course digoxin is  associated with an improvement of  heart function parameters  and decrease of hospital length of stay.

 

 

Asma KHALFALLAH (Mahdia, TUNISIA), Amel MARSIT, Adel SEKMA, Mohamed Amine MSOLLI, Kaouther BELTAIF, Hamdi BOUBAKER, Semir NOUIRA
11:00 - 11:05 #19062 - SP076 The sum of st segment depression and severity of coronary artery disease in non-st segment elevation acute coronary syndrome.
SP076 The sum of st segment depression and severity of coronary artery disease in non-st segment elevation acute coronary syndrome.

Background: The electrocardiogram (ECG) remains central in the risk stratification of non ST-segment elevation acute coronary syndrome (NSTEMI). The ST segment depression appears to be the most predictive marker of mortality at day 30 and at one year. Recently, many studies had demonstrated that the sum of ST-segment depression provides much more information than the simple qualitative assessment of ST-segment depression>0.5 mm.

Objective: To find out the association between the sum of magnitude of ST segment depression and angiographic severity in NSTEMI patients.

Methods: A prospective observational study was conducted over six years. Patients with the diagnosis of NSTEMI and an ST segment depression > 0.5 millimeters (mm) in at least one lead were included. ST segment depression was measured and the cumulative sum of the ST-segment depression, in mm was calculated. The location, the number of leads with ST segment depression was also measured in all ECG leads. The prognosis was based on the evaluation of major adverse cardiac event (MACE) at six months.

Angiographic severity was assessed by a validated vessel score. The sum of the magnitude of ST segment depression was correlated with angiographic severity of coronary artery disease.

Results: Inclusion of 287 patients. Mean age was 62±11 years. Sex ratio = 1.7. Comorbidities (%): hypertension (59), diabetes (45), dyslipidemia (33), coronary artery disease (28). Mean sum of ST segment depression was 5 [1,28].

Mean delay of door to balloon = 4 hours [1, 72]. Twenty seven percent of patients developed a MACE.  In multivariate analysis a cumulative sum of ST-segment depression > 7 mm (adjusted OR = 5.34, p <0.001, 95% CI [2.71 to 10.51]) was independently associated with MACE at six months.

Positive correlation was found between the sum of ST segment depression, the number of leads with ST segment depression and the severity of coronary artery disease with (r=0.352; p<0.0,1) and (r= 0.361; p<0.001) respectively. 

Conclusion: This study shows that the sum of ST segment depression in all ECG leads is a powerful predictor of severity of coronary artery disease.

 

Hela BEN TURKIA (BEN AROUS, TUNISIA), Syrine KESKES, Wided BAHRIA, Ines CHERMITI, Mahbouba CHKIR, Sami SOUISSI, Hanen GHAZALI, Jamila HABLI, Souad CHKIR

Tuesday 15 October

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EPOSTER 4.5
10:45 - 11:05

ePoster 4.5 - Short Oral Presentation - Screen 5

10:45 - 10:50 #18497 - SP077 New infant chest compression technique. A randomized, crossover, simulation trial.
SP077 New infant chest compression technique. A randomized, crossover, simulation trial.

Background:

The ability to perform high quality chest compressions is one of the basic skills that medical staff should have. Current CPR guidelines recommend performing chest compression in infants and newborns using either two fingers (TFT) or two thumbs (TTHT). However, both have their advantages and disadvantages. In the first case, as shown by the studies, there is full chest recoil, however, the chest is pressed too shallow, in the second case the results are the opposite. The aim of the study was to compare these two methods with the authors' own new method of chest compression. 

Methods:

This was prospective, randomized, crossover, observational, simulation trial. The study involved 60 nurses who participated in Basic Life Support trainings. After the correct demonstration of the recommended compression methods (TFT and TTHT) and the innovative chest compression method (nTTT) based on thumbs perpendicular to the chest,  the participants had the opportunity to practice individual methods with the use of an infant simulator. During the study, participants were asked to perform 2-minute neonatal resuscitation based on continuous chest compression. Both the sequence of participants and methods of chest compression were random and ResearchRandomizer was used for this purpose. The study analyzed the depth and rate of chest compression as well as the correctness of chest recoil.

Results:

The study involved 60 nurses whose median age was 43 years (IQR; 32-48), and work experience achieved 17 years (IQR; 5-25). The median depth of chest compression based on particular compression techniques (TFT, TTHT, nTTT) was differentiated and achieved 32 mm (29-35) vs. 41 mm (37-42) vs. 40 mm (37-42; p<0.001) respectively. The rate of compression was the highest for TFT and was 127 (118-130) compressions per minute (CPM), followed by 115 CPM (108-122) and 112 CPM (102-120; p<0.001) for TTHT and nTTT (102-120; p<0.001), respectively. Correctness of chest recoil was 96% (83-100) for TFT, 35% (29-43) for TTHT, and 96% (89-100) for nTTT.

Discussion and Conclusions:

The results of the study show that the nurses participating in the study performed the highest quality chest compressions on the newborn using the new authors method of chest compression nTTT. Further research is needed to verify the results obtained in the study. 

Szarpak LUKASZ, Smereka JACEK (Wroclaw, POLAND), Gorczyca DAMIAN, Evrin TOGAY, Plusa TADEUSZ, Katipoglu BURAK
10:50 - 10:55 #18711 - SP078 Interactive effect of multi-tier response and advanced airway on good neurological recovery after out-of-hospital cardiac arrest.
SP078 Interactive effect of multi-tier response and advanced airway on good neurological recovery after out-of-hospital cardiac arrest.

OBJECTIVES: High-quality CPR including early defibrillation, uninterrupted chest compression and optimal airway management are primary components associated with return of spontaneous circulation (ROSC) and preventing neurological impairment. We hypothesized that the multi-tier response will provide higher quality of CPR including airway management, but the type of combination will make different interaction to the airway management for outcomes after OHCA. The aim of this study was to determine the effect of advanced airway management method on outcomes and compare the effect size across the multi-tier response type on outcomes after OHCA.

METHODS: This study was a retrospective and observational cohort study utilizing the Korea OHCA Registry (KOHCAR), which included all adult EMS-assessed OHCA patients with presumed cardiac etiology. The study period was from January 2015 to December 2017. Airway management methods were categorized into the endotracheal intubation (ETI) group and supraglottic airway (SGA) group. Tier system were divided into single-tier response and two types of multi-tier response (MTR) including an ambulance-ambulance multi-tier response (ATR) and an ambulance fire engine multi-tier response (FTR). Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to show the association between airway management/tier type and patients with ROSC rate, survival to discharge rate and neurological outcomes. Multivariable logistic regression analysis performed to assess the interaction effects of airway management method and tier type.

RESULTS: Among 87,551 EMS-assessed OHCAs during the study period, a total of 25,888 patients were analyzed. In comparison of single-tier response and MTR type, ATR was significantly associated with higher ROSC rate, survival to discharge and neurologic outcomes than single-tier response. However, there was no significance difference between FTR and single-tier response. Interaction analysis shows that regardless of tier type, SGA was significantly lower ROSC rate than ETI.

CONCLUSION: In this nationwide observational cohort study, we observed that ATR provide good clinical outcomes than single-tier response or FTR. And regardless of tier system, SGA showed significantly lower ROSC rate than ETI. The indeterminate evidence of optimum airway management and tier type for OHCA has encouraged calls for randomized controlled trials to clarify precise circumstances, patients’ conditions and characteristic of the EMS system and survival outcomes.

Hyouk Jae LIM (Seoul, KOREA), Joo JEONG, Kihong KIM, Jungeun KIM, Young Sun RO, Sang Do SHIN
10:55 - 11:00 #19132 - SP079 The Prognostic Value of Pulse Oximetry (POP) Waveform During Cardiopulmonary Resuscitation.
SP079 The Prognostic Value of Pulse Oximetry (POP) Waveform During Cardiopulmonary Resuscitation.

Background and Objectives
Quality of cardiopulmonary resuscitation(CPR) is associated substantially with the mortality and morbidity of cardiac arrest patients. However, there is little technology available to provide non-invasive real-time feedback on the effectiveness of CPR. Blood Oxygen Saturation (SpO2) waveform is associated with intention, frequency, and interruption of chest compression. In this study, we tend to examine whether finger pulse oximeter plethysmograph(POP) waveform can be used to monitoring the effectiveness of CPR.
Methods
This was a prospective multicenter observational study that includes emergency departments from 14 teaching hospitals in China from 2013 - 2014. All patients with out of hospital cardiac arrest (OHCA) were enrolled in this study. Patients who enrolled were resuscitated according to 2010 AHA CPR guideline. Demographic information, ECG, pulse oxygen saturation, PetCO2 during CPR was collected. The area under the POP curve (AUCp) and amplitude of the curve (Amp) was recorded and analyzed between those with and without return of spontaneous circulation (ROSC). Furthermore, predictive value was also compared between POP curve and PetCO2.

Results
617 OHCA patients were admitted during the period of our study, among them, 400 were finally enrolled. 102 patients got ROSC in the emergency departments while 298 patients without. Among patients with ROSC AUCp, Amp, and PetCO2 was significantly higher compared to those without ROSC (all p<0.05). Both AUCp and Amp had good correlation with PetCO2. In addition, cutoff value of AUCp> 2726 PVPG and Amp>58 PVA had a predictive value of ROSC with a sensitivity of 0.81 and 0.80, specificity of 0.67 and 0.68 respectively. On the other hand, PetCO2 in our study with cutoff value of 14.5mmHg had a sensitivity of 0.676 and specificity of 0.565 to predict ROSC.
Conclusions
POP may be used as a novel method for feedback of the effectiveness of CPR.
Yu XUEZHONG, Xu JUN (Beijing, CHINA), Jin KUI
11:00 - 11:05 #19234 - SP080 Point-of-care Ultrasound role in the modern Emergency Physician’s practice in Romania.
SP080 Point-of-care Ultrasound role in the modern Emergency Physician’s practice in Romania.

BACKGROUND:

Point-of-care ultrasound (POCUS) offers additive value in the diagnosis and treatment of emergency and/or critically ill patients. To help spread this medical practice in Romania within the nonradiologist community, under EUSEM guidance we conducted a POCUS course. The course was done in a single major university medical centre of Romania under the guidance of established POCUS faculty.

OBJECTIVE:

Our aim was to characterize the current practice of emergency physician and the effect of the POCUS course on the practice of junior, registrar and consultant level doctors that had no or not enough previous ultrasound (US) experience.

METHODS:

A 11-question anonymous survey was emailed to 40 graduates over a 4-week period, before the course and 2 months after attending.  All the participants had as their primary speciality Emergency Medicine.

No incentives were provided for completion of the questionnaire. Descriptive statistics are reported.

RESULTS:

A total of 21 participants completed the study for a response rate of 52.5%.

For the vast majority of them, this was the first ultrasonography course they attended, but 28.7% attended an US course previously.

 

Out of the doctors that completed the questionnaire 66,66 % were registrars, 28,58% consultants and just 4,76% junior doctors. Interesting note is the fact that although without previous formal training 71,42% were already using US in their practice, this percentage increasing to 100% after attending the course. Those that used US in their daily practice used it quite rarely, 47,61% reporting using it less than 2 times per month, justifying this due to lack of time (66,66%) but also lack of legislation to support them (28,57%). 33.33% of the participants also named the lack of trust of other specialities as an important discouragement. The main situations in which US was used in the ED was to check for cardiac activity in PEA (76,19%), detecting free intraabdominal fluid in trauma (57,14%) and facilitating invasive procedures such as central venous access and pleural taps. A majority also used POCUS to guide them in the ALS protocols especially in reversible cases such as hypothermia and cardiac tamponade but also in making decisions to stop resuscitation.

The second questionnaire showed an increase in US usage in the ED but the users did not rely on their findings and requested second opinions in severe cases.

 

CONCLUSION: The analysis shows that the interest in POCUS, especially in the Emergency Department, is quite high in Romania. This tendency is more common in the younger generation of doctors (juniors and registrars) who prefer to use it in answering quick FAST questions but also aiding in making tough ALS/ATLS protocol decisions and in invasive procedures. Further similar undertakings will probably open ground for more US based protocols making this practice more common in Romania and Easter European countries.

Emergency ultrasound should be introduced into an emergency medical service area as a diagnostic modality that provides benefits to patients. Emergency physicians have to be specifically trained and to participate in continuous education activities.

Catalin BOUROS, Mihaela CORLADE, Ovidiu Tudor POPA, Paul NEDELEA, Andrei HANCU, Gabriela GRIGORAS, Anca HAISAN, Diana CIMPOESU (IASI, ROMANIA)
15:45

Tuesday 15 October

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EPOSTER 5.1
15:45 - 16:05

ePoster 5.1 - Short Oral Presentation - Screen 1

15:45 - 15:50 #17922 - SP081 What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?
SP081 What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?

Background

The year 2013 saw the publication of minimum standards for medical teams working internationally in response to disasters.  This has been a true game-changer and pivot point for emergency medical team (EMT) practice worldwide and has set in motion a process of world health organisation (WHO) verification which seeks to ensure that EMTs are working to a minimum acceptable standard and when called upon to assist a foreign government with a disaster, they are actually able to perform as expected.  Within this process it was recognised that in order for EMTs to develop to this standard, certain guidelines for best practice would be needed.  One area which warranted its own working group was the minimum data set (MDS) for daily reporting.  In 2017 the WHO produced its first MDS for EMT daily reporting during sudden onset disasters (SODs), following expert consensus.  The initial challenge lies in ensuring EMTs adopt this MDS under the direction of in-country ministries of health (MoHs). However the subsequent challenge is understanding the utility of the data to help resource-manage an acute response.  This study looks at the specific coding of injuries to determine how reproducible the coding of severity is between practitioners using the WHO EMT MDS.

Methods

25 clinical case vignettes were developed to reflect potential injuries encountered in a SOD. These were presented in an online format between April and July 2018 to practitioners who have experience of/training in managing patients in SODs.  The pool of participants was derived from three sources: UK-Med’s register members, the Australian Medical Assistance Team (AUSMAT)’s Northern Territory members and the New Zealand Medical Assistance Team (NZMAT) clinical members.  UK-Med hosts and trains National Health Service (NHS) medical staff for the UK Emergency Medical Team (UK EMT) and both AUSMAT and NZMAT have a register of practitioners engaged in and interested in disaster response.  The participant pool was restricted to those who encounter injured patients in their clinical practice.  Practitioners were asked to code each injury according to the WHO EMT MDS case classifications.  Randolph’s kappa statistic for free-marginal multi-rater data was calculated for the whole data-set as well as subgroups to ascertain inter-rater agreement

Results

86 practitioners responded, giving >2000 individual case responses. Overall agreement was moderate at 67.9% with a kappa of 0.59 [CI 0.49,0.69].  Despite subgroups of paramedics (kappa 0.63 [CI 0.53,0.72]), doctors (kappa 0.61 [CI 0.52, 0.69]) and those with disaster experience (kappa 0.62 [CI 0.52, 0.71]) suggesting slightly higher agreement, their CIs (and those of other subgroups) suggest overall similar and moderate levels of practitioner agreement in classifying severity of injury.

Conclusions

An inter-rater agreement of 0.59 is considered moderate, at best, however it gives MoHs some sense of how tightly they may interpret injury data derived from daily reports using the WHO EMT MDS.  Similar studies, with weighting for injury likelihood using sample data from true SODs would further refine the level of interrater agreement to be expected. Consequently MoHs may develop appropriate frameworks of resource allocation during SODs.

Anisa Jabeen Nasir JAFAR (Manchester, UK), Jamie C. SERGEANT, Fiona LECKY
15:50 - 15:55 #18320 - SP082 Understanding the perceptions of emergency physicians and general surgeons with regards to the diagnosis, management and the use of POCUS in acute cholecystitis.
SP082 Understanding the perceptions of emergency physicians and general surgeons with regards to the diagnosis, management and the use of POCUS in acute cholecystitis.

INTRODUCTION: 

Patients presenting with acute cholecystitis to the emergency department will often have to wait for a diagnostic radiology performed ultrasound (US). Point of care ultrasonography (POCUS) with targeted images of the gallbladder has the potential to assist in early identification and expedite management. Our objectives are to identify the clinical features and the potential role that POCUS may have for emergency physicians (EPs) and general surgeons (GS) in the diagnosis of acute cholecystitis in the emergency department.

 METHODS: 

An electronic survey with questions relating to diagnosis, management and use of biliary POCUS in patients with acute cholecystitis was devised. The survey was pilot tested by two EPs and two GS. Staff EPs and GS at an urban academic hospital were invited to participate in the survey using a modified Dillman method as part of a quality improvement project. Descriptive statistics were used to analyze the data.

 RESULTS:

The response rate for EPs was 76% (59/78) and GS was 68% (17/25). Both EPs and GS used a constellation of clinical signs and symptoms, laboratory and radiological investigations for the diagnosis of acute cholecystitis. Only 22% of EPs and 18% of GS were confident in interpreting US images for acute cholecystitis with most not reviewing or interpreting radiology performed US images in the course of patient care. Although most EPs (95%) utilize POCUS in their daily practice, only 39% of EPs perform biliary POCUS, citing limited exposure and training and non-acceptance by GS as main barriers to use. None of the GS perform biliary POCUS themselves and 70% did not feel comfortable using biliary POCUS to diagnose acute cholecystitis. In three different clinical scenarios involving patients presenting with acute cholecystitis in the emergency department with POCUS findings presented, over 80% of ACS respondents were willing to accept consultation from EPs while awaiting radiology US and 44% were willing to admit in a typical scenario prior to radiology US with only one GS willing to take to the OR without radiology US. GS identified the following that would improve acceptance of POCUS in the diagnosis of acute cholecystitis - improved training and decreased operator variability, access to POCUS images, and clear written interpretation of POCUS images on the medical record, recognizing that POCUS is not a replacement for pre-operative imaging but to improve ED length of stay (LOS) and expedite ED management.

 CONCLUSIONS:

Our survey has identified important clinical and imaging features for the diagnosis of acute cholecystitis in the emergent setting by EPs and GS, especially with regards to expectations and perceptions of the use of biliary POCUS. Both EPs and GS have identified a willingness to incorporate POCUS for patients with acute cholecystitis to potentially improve ED LOS. Quality improvement initiatives that include education, training, and change in work processes can now be directed to incorporate POCUS in the diagnosis of acute cholecystitis for both EPs and GS.

Bao Yu Geraldine LEONG (Singapore, SINGAPORE), Peter GLEN, Edmund KWOK, Brandon RITCEY, A SHEIK, Michael WOO
15:55 - 16:00 #18575 - SP083 An initiative to improve the quality of point-of-care testing within critical care settings by targeting the pre-analytical phase.
SP083 An initiative to improve the quality of point-of-care testing within critical care settings by targeting the pre-analytical phase.

Background

Availability of rapid and high quality test results offered by Point-of-care testing (POCT) speeds up clinical decision making in critical care settings.  POCT sampling and analysis is usually performed by non-laboratory staff with varying levels of experience. Several pre-analytical pitfalls can dramatically reduce the quality of the POCT result, regardless of the analytical quality of the test.

Aim

Present study aimed to identify pre-analytical challenges of POCT within critical care settings.

Methods

Issues influencing the quality of the POCT result - apart from the analytical quality - were collected during focus conversations and in-person consensus meetings with POCT experts from different European countries and different professional backgrounds (clinical laboratory, ICU, nursing).  

Results

Main areas identified in the pre-analytical phase were: patient and user safety, user and analyser related errors, timeliness expressed as turn-around-time (TAT), training and competence testing of the user, connectivity and over-all quality of the test result (apart from the analytical quality).

The specific challenges in these areas were further detailed. 

Patient safety is negatively impacted by human errors such as incorrect identification of the patient or incorrect ethnography assessment, by blood & sharps exposure, and by delayed, incomplete or erroneous data transfer.  User safety is impacted by blood and sharps exposure.

Human and material errors reported by instruments lead to wasted samples and test materials and cause sample recollection and retesting, prolonging the TAT. TAT is also negatively impacted by high complexity testing. A prolonged TAT negatively impacts patient waiting time and time to medical decisions, thereby decreasing the effectiveness of the test and also has a negative impact on staff time and workflow, thereby decreasing efficiency and increasing working costs.

The most important key factor defining pre-analytical quality is training and competence of the user.  Training and (re)certification of POCT users should be provided by the laboratory’s POCT coordination team.  Lab support frees users of practical and logistical issues concerning POCT such as analytical quality issues, follow-up of lot numbers, expiry dates and quality controls.  POCT coordinators are lab experts trained to provide this support.  Higher user-friendliness of the equipment decreases the necessary training.

Connecting POCT instruments to the Lab Information System and the Electronic Health Record of the patient is an essential contributing factor to correct patient and user identification and to full traceability of the POCT result.

Quality of the test result is negatively impacted by incorrect procedures, such as waiting too long to test the sample, incorrect filling of sampling devices, insufficient sample, haemolysis, improper mixing, improper air evacuation.   

Suggested measurable key performance indicators for the pre-analytical phase are instrument down-time and percentages of incorrect patient and user ID’s, no-result samples, instrument error codes, out-of-control QC results, interventions by POCT coordinator and manufacturer.

Conclusion

We conclude that this initiative has identified several pre-analytical key factors determining the over-all quality of POCT.  A future study is planned to measure the above-mentioned key performance indicators for the pre-analytical phase in real-life critical care settings.

Viviane VAN HOOF (Antwerp, BELGIUM), Suzanne BENCH, Antonio BUÑO SOTO, Antoine GUILLON, Peter LUPPA, Ulf Martin SCHILLING, Annette THOMAS, Andrei N TINTU
16:00 - 16:05 #18902 - SP084 Prevalence of cause and unnecessary emergent brain Computed Tomography (CT) scan among patients with non-penetrating head trauma; A cross-sectional study.
SP084 Prevalence of cause and unnecessary emergent brain Computed Tomography (CT) scan among patients with non-penetrating head trauma; A cross-sectional study.

Introduction: Prevalence of brain injuries is estimated at about 200 people per 100,000 in developed countries and more than 500 people per 100,000 in the United States. CT scan is in fact a selective method for evaluating patients with skull trauma. More than 98% of hit-head imaging did not have positive finding. This study aimed to evaluate the frequency of CT scan requests without indication in patients with head trauma in Rasoul–e Akram, Firoozgar and Haft-e-Tir university hospitals.

 

Methods: In this cross-sectional study, patients who were referred to our hospitals with chief complaint of head trauma, during study period, were retrospectively assessed for eligibility. Patients were selected through hospital information system (HIS) and using consensus sampling method. Demographic information of patients as well as signs, symptoms and brain CT scan results were recorded in a predesigned checklist. In the present study, considered brain CT scan indications were resulted from integration of Canadian CT Head Rules, NICE Head Injury Guideline, ACEP Clinical Policy (Rosen) and New Orleans Criteria guidelines.

 

Results: Eventually 464 (322 male and 142 female) patients were investigated. Mean age of patients was 35.11±18.3 years old and mean GCS score at the time of primary assessment was 14.46 ±2. Fourty-five patients who were referred or attended to our hospitals did not have intended indications but CT scan was requested for them. Finally 86 cases did not have indications for CT scan among which 41 cases were correctly diagnosed by physicians and CT scan was not performed on them.

 

Conclusion: In conclusion the result of the present study revealed that about 11% of performed CT scans in trauma patients are unnecessary and without related indications.

 

Mahdi REZAI (Tehran, IRAN, ISLAMIC REPUBLIC), Neda ASHAYERI, Farzaneh BEIGMOHAMMADI, Mohammadhosein GHAFOURI ABBASABADI

Tuesday 15 October

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EPOSTER 5.2
15:45 - 16:05

ePoster 5.2 - Short Oral Presentation - Screen 2

15:45 - 15:50 #18898 - SP085 Ceftriaxone Usage in the Academic Emergency Departments: Evidence Based Utilization or overuse.
SP085 Ceftriaxone Usage in the Academic Emergency Departments: Evidence Based Utilization or overuse.

Introduction: Ceftriaxone is being used, widely, these days, and it is less according to the current guidelines. The aim of this study was to determine the appropriate usage of ceftriaxone. Considering the results may help looking for a way to prevent its inappropriate use in Emergency Department (ED).

Methods: In an observational-analytical study, the patients referred to EDs of two teaching hospitals since September 23, 2017 to March 19, 2018 who have been treated with ceftriaxone, were analyzed. The rational usage of ceftriaxone was determined based on latest evidence based literatures.

Results: Ceftriaxone had been prescribed properly in 156 patients (38.4%; 95% CI, 33.5-42.9%) and its use did not meet logical criteria in the rest of cases consisting of 250 patients (69.6%; 95% CI, 57.1-66.5%). Logical use of ceftriaxone was independently related to treatment-goaled use, level I triage, urinalysis (U/A) compatible with urinary tract infection (UTI), and chest radiographic evidence of pneumonia.

Conclusion: Our study revealed a range of appropriate use of ceftriaxone not acceptable for a teaching medical center; more education seems to be necessary in this field.

Mahdi REZAI (Tehran, IRAN, ISLAMIC REPUBLIC), Hasan SAFEHIAN, Neda ASHAYERI
15:50 - 15:55 #19043 - SP086 Risk Stratification and Age-Adjusted D-Dimer Test: Are They Satisfactory in Acute Pulmonary Embolism?
SP086 Risk Stratification and Age-Adjusted D-Dimer Test: Are They Satisfactory in Acute Pulmonary Embolism?

PURPOSE: Pulmonary embolism (PE) is associated with high morbidity and mortality and often has a nonspecific clinical presentation. The use of diagnostic testing to reduce the risk of missing a potentially life-threatening diagnosis increases both the cost of care and the use of medical resources. Various score systems exist to evaluate the probability of PE, which can also be used for risk stratification to obtain the most accurate diagnosis. The aim of our study was to review the evidence for existing prognostic models in acute PE and determine their validity and usefulness for predicting patient outcomes. We also determined the accuracy of an age-adjusted D-dimer threshold to detect PE.

METHODS: The study involved the retrospective application of an age-dependent D-dimer cut-off (age/100 in patients aged >50 years) in 659 consecutive patients, both in and outpatients, aged ≥18 years who had undergone CT pulmonary angiogram for suspected PE according to the European Society of Cardiology (ESC) guidelines. We included individuals who presented to an emergency department with a suspicion of PE and who were then referred for objective testing; all participants included were capable of providing informed consent. This study was performed in three emergency departments in Hungary between January 2016 and September 2018. We retrospectively collected information regarding symptoms (dyspnoea, unilateral leg swelling, and haemoptysis), vital signs, and medical and social history (cancer, recent surgery, medication, history of deep vein thrombosis or PE, and chronic obstructive pulmonary disease). We calculated test characteristics, including sensitivity and specificity. We applied three different D-dimer approaches to the low and moderate-probability patients. The primary outcome was exclusion of PE with each D-dimer approach, while the secondary objective was to estimate the negative predictive value for each rule. Data were analysed using SPSS 24.0 statistical software.

RESULTS: In the 659 cases (407 women and 252 men), a total of 105 D-dimer assays, 51 CT angiograms, and 212 chest X-ray examinations were carried out redundantly; if these procedures were not carried out, it could have saved money for the hospitals and reduced radiation exposure for patients. The age-adjusted D-dimer threshold was more specific (70% versus 60%) but less sensitive (95% versus 98%) than risk stratification. The sensitivity of the combined technique (risk stratification and age-adjusted D-dimer test) was 100%.

CONCLUSION: Our study showed that Geneva score (which was calculated from the patients’ complaints, medical history, and physical examination) had the closest correlation with the true diagnosis. An age-adjusted D-dimer limit has the potential to reduce the need for diagnostic imaging and is more accurate than the standard threshold of 500 ng/dL. The combination of risk stratification and age-adjusted D-dimer can be used to safety diagnose PE. Finally, we can conclude that risk evaluation in acute PE is indispensable and the appropriate use of guidelines results in lower healthcare costs. Our data support the use of age-adjustment and perhaps adjustment for other factors also seen in patients evaluated for PE.

Attila PANDUR (Pecs, HUNGARY), Balint BANFAI, Agnes PANDUR-SARKANY, Henrietta BANFAI-CSONKA, Bence SCHISZLER, Jozsef BETLEHEM, Balazs RADNAI
15:55 - 16:00 #19058 - SP087 Adjustment of Early Warning Score by clinical assessment to improve detection of acute deterioration in hospitalized patients, a feasibility study.
SP087 Adjustment of Early Warning Score by clinical assessment to improve detection of acute deterioration in hospitalized patients, a feasibility study.

Background: Serious Adverse Events in hospitalized patients, such as unanticipated admission to Intensive Care Unit and cardiac arrest, are often preceded by deteriorating vital signs. Early Warning Scores (EWS) are used to allow detection of deterioration. EWS systems is implemented based on the strong association between vital sign abnormalities and poor outcomes shown in several retrospective studies. Only few studies have examined the clinical impact of EWS.

Individual Early Warning Score (I-EWS) is a newly developed track and trigger system where the assessment of vital signs by EWS is combined with a clinical assessment of the patient. This combination has in a previous randomized study improved triage of acutely admitted patients. Prior to comparing I-EWS to the already implemented National Early Warning Score (NEWS) in a prospective cluster-randomized crossover multicenter study, a feasibility study was performed.  The aim was to test the use of I-EWS in a clinical setting and to explore the nursing staff’s experience with I-EWS.

Methods: We performed a feasibility study of the implementation of I-EWS. I-EWS is integrated as a mandatory part of the electronic health care journal. Vital signs are registered, and an aggregated score calculated. Nursing staff is asked to revise the score based on their clinical assessment. The score can be adjusted with a maximum of -4 or +6 points or kept unchanged if the score matches the patient’s clinical presentation. We recorded the number of I-EWS scores and the proportion of up- and down adjustments of the scores. A questionnaire was sent electronically to the staff subsequently to assess the level of information about I-EWS and the applicability of I-EWS. As well as to assess the nursing staff’s perception of I-EWS as a track and trigger system. Data was collected at Herlev and Gentofte Hospital, a 949-bed University Hospital in the Capital Region of Denmark. Eight medical and surgical wards with a total of 250 beds used the I-EWS for a 2-week period in June 2018. Ambassadors from every ward, participated in an introduction course prior to initiation of the study. The Ambassadors introduced their colleagues to I-EWS.  

Results: We recorded 5669 observations during the study period. I-EWS was used in 4585 (80.9 %) of the observations by the end of the second week. Of these scores 876 (19.1 %) were downgraded and 116 (2.6 %) were upgraded. Eighty-one of the 181 questionnaires (45%) were returned and 65.4% were very satisfied/satisfied with the level of information and 16 % answered neither nor. 80.3 % found the registration of I-EWS easy. Less than 6.7 % found no clinical relevance of I-EWS.

Conclusions: The possibility to adjust EWS was feasible and well received among hospital staff. The effect of I-EWS being tested in an ongoing multicenter study that is ongoing.

Pernille B. NIELSEN (Copenhagen, DENMARK), Martin SCHULTZ, Caroline LANGKJAER, Niels Egholm PEDERSEN, Anne Marie KODAL, Michael Dan ARVIG, Christian S. MEYHOFF, Bibi HØLGE-HAZELTON, Morten BESTLE, Gitte BUNKENBORG, Anne LIPPERT, Ove ANDERSEN, Lars Simon RASMUSSEN, Kasper K. IVERSEN
16:00 - 16:05 #19383 - SP088 An observational study of older adults admitted to the head injury ward.
SP088 An observational study of older adults admitted to the head injury ward.

An observational study of Older adults admitted to the head injury ward

 

Introduction

 

Head injuries in the older adult population are an increasing presentation to the emergency department as a result of an aging population. The cause of injuries can be more complex in the frail older adult, require further investigations and multidisciplinary input to facilitate safe discharge home.

 

Our department at the Royal Alexandra Hospital (RAH) in Paisley, Scotland serves a population of approximately 200,000 people with approximately 750 beds.  The RAH has a dedicated ward for head injuries managed by Emergency Department (ED). consultants. It provides inpatient observation of patients unsuitable to discharge home from the ED who have sustained a head injury. Patients can be admitted who do not require a CT scan, a normal CT result, or who have sustained an intracranial bleed which does not require operative input after discussion with neurosurgical colleagues.

 

This ward aims to manage symptoms, observe those without social support and discharge patients within 48 hours. Patients with clear other care needs are admitted under the appropriate speciality. Presentations of frail older adults are the most complex to manage and ensuring appropriate care by the right team can improve patient outcomes in this group.

 

We wanted to determine if the cohort of frail patients are inappropriately admitted under the care of the ED as they do not meet criteria from initial presentation that would allow discharge within 48 hours due to increased care needs.

 

Methods

 

This retrospective cohort study reviewed medical notes of all patients aged over 65, admitted to the head injury ward over a 1-year period (Jan 2018-Jan 2019).

 

Frailty was assessed using the F.R.A.I.L screening tool. A patient is deemed frail if there is evidence of:  functional impairment due to significant co-morbidity, a care-home resident, documented acute confusion, impaired mobility, or require increased support on discharge.

 

Results

 

116 patients were admitted and reviewed, the median age was 79.(Minimum 67 and maximum 98 with an average of 79) Average length of stay on the head injury ward was 1.94 days.

 32/166 patients were referred to a different inpatient speciality following admission to the head injury ward.

45/116 of patients were regarded as frail. Their average length of stay was 2.6 days and 15/45 were referred to other specialities compared with 1.52 days and 17/71 respectively in the non-frail group.

 

 

 

Discussion

 

We found 95/116 patients over 65 admitted to our head injury ward were appropriately admitted and discharged within 48 hours. However, 40% were described as frail when using the frailty scoring tool. Notwithstanding a degree of hindsight bias, the results show that this cohort have a prolonged LOS and require subsequent transfer to another speciality during admission.

 

Head injuries in older adults can be the result of disequilibrium in a complex, frail patient and the use of frailty screening tools in the ED can help identify those patients requiring specialist input from elderly care teams rather than admission to a short stay ward and subsequent transfer.

Emma CLARK (Glasgow, UK), Jonathan RITCHIE, Christopher DALE, Jennifer COCHRANE

Tuesday 15 October

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EPOSTER 5.3
15:45 - 16:05

ePoster 5.3 - Short Oral Presentation - Screen 3

15:45 - 15:50 #18611 - SP089 Victims of the road accidents at the Emergency Room of Sibiu.
SP089 Victims of the road accidents at the Emergency Room of Sibiu.

Background:

Road Accidents cause the occurrence of a large number of victims in Romania,  trauma cases specifically requiring medical teams starting from Mobile Emergency Service for Resuscitation and Extrication, to complex surgery and the Intensive Care Teams. This aspects led to the need for a study, which emphasises several important elements, of the cases in the last three year. Thus, we used criterions like mainly pathology, the age and the annual distribution of the victims, area where the car crashed, association of alcohol consumption and the state in which the patient was brought to Emergency Room of Sibiu.

Methods:

We conducted a retrospective observational study on a total of 189.397 patients presented at the Emergency Room of Sibiu County Emergency Clinical Hospital, between 01.01.2016 and 31.12.2018.

Results:

From the total of 189.397 patients, in the Emergency Department were reported 1084 victims of road accidents.

We examined how many pacients were brought in the Emergency Trauma Room every year and the results are:

2016 - 401 (36,99%) victims

2017 - 311 (28,69%) victims

2018 - 372 (34,31%) victims

The age distribution during the study was the following:

Age category 18-20 years old:   31 cases (2,85%)

Age category 21-30 years old: 298 cases (27,49%)

Age category 31-40 years old: 210 cases (19,37%)

Age category 41-50 years old: 209 cases (19,28%)

Age category 51-60 years old: 145 cases (13,37%)

 

We were interested to assess the areas from which patients were brought in the Emergency Room and the results are:

Urban Area: 738 (68,08%)

Rural Area:  346 (31,91%) 

 

369 (34,04%) Patients had suffered cranio-cerebral trauma of which:

210 (56,91%) associated one or multiple Contusions

108 (29,26%) were Poly-Traumatized 

 

17,80%, meaning 193 victims, drunk alcohol before driving and had positive results using Breath Test. 

 

Discussion & Conclusions:

The main category of patients injured in crashes is included in the age range between 21 and 30 years old, mostly because lack of preventive behavior.

Although not statistically representative, it is clinically significant that a fairly large number (about one third) of victims presented cranio-cerebral trauma, so we can conclude the fact that vehicles, even if equipped with modern safety systems, are still not prepared to efficiently protect the cephalic extremity, which is actually the most exposed area of the body in the case of road accidents.

There are still situations when drivers are choosing to drive despite having consumed alcohol before.

The large number of victims brought to the Emergency Room from the Urban Area is primarily due to heavy traffic in the crowded cities.

Cristian ICHIM (Sibiu, ROMANIA), Ana Daniela ŢĂRAN, Iulia ANDREI, Maria-Ioana OANA-ALBU, Ştefania Noemi OPRIŞ, Răzvan - Marius DOBRE, Diana - Ionela CHECIU
15:50 - 15:55 #18660 - SP090 Low dose of inhaled Methoxyflurane: more effective and rapid-acting than standard analgesic treatment, also for severe trauma-related pain: subgroup analysis of a randomised controlled trial (InMEDIATE).
SP090 Low dose of inhaled Methoxyflurane: more effective and rapid-acting than standard analgesic treatment, also for severe trauma-related pain: subgroup analysis of a randomised controlled trial (InMEDIATE).

Background

Currently available analgesic options for severe pain in the emergency setting have limitations such as the challenging safety profile of opioids and limited efficacy of weaker analgesics. Inhaled methoxyflurane is an easy-to-administer, rapid-acting, non-narcotic analgesic that has been used in emergency settings in Australia and New Zealand since the 1970s and is now approved in Europe. InMEDIATE was a pragmatic trial in Spanish emergency units (including one pre-hospital unit) that compared the pain relief achieved with methoxyflurane versus standard analgesic treatment (SAT, administered according to each site’s own analgesic protocol).; we report results of a subgroup analysis in patients with severe pain (NRS ≥7).

 

Methods

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a Phase IIIb, open-label, randomised controlled trial conducted from July 2017 to April 2018 by the Pain Group of the Spanish Society of Emergency Medicine/Spanish Clinical Research Network. At triage, eligible patients with moderate-to-severe trauma pain (score ≥4 on the Numeric Rating Scale [NRS]) were randomised 1:1 to receive inhaled methoxyflurane (up to 2´3mL) or SAT whilst 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. Primary efficacy endpoint was change in NRS pain intensity, co-primary endpoint was time to onset of pain relief and patient/clinician-reported outcomes were secondary endpoints. The treatments were compared for the severe pain subgroup (NRS ≥7; N=165) in an exploratory manner using 2-tailed t-tests.

 

Results

The methoxyflurane group included 89 patients, mean age 47.8±19.8 years, 55% male. The SAT group included 76 patients, mean age 45.6±17.9 years, 47% male; 86% received non-opioid analgesia (mostly intravenous NSAIDS) and 13% received opioids. Main injury types were contusion (N=96), fracture (N=43) and swelling (N=27). Mean NRS pain intensity at baseline, 3, 5, 10, 15 and 20min was 8.57±0.82, 6.73±1.70, 5.73±1.91, 4.59±2.19, 4.02±2.32 and 3.32±2.23 for the methoxyflurane group and 8.68±0.78, 8.08±1.38, 7.56±1.70, 6.70±1.91, 5.87±2.30 and 5.20±2.47 for the SAT group. The decrease from baseline was significantly larger for methoxyflurane than SAT at all time points (p<0.001), with the largest treatment difference at 10min (-2.11; 95% CI: -2.75, -1.47; p<0.001). Methoxyflurane-treated patients first reported pain relief at a mean of 6.13min compared with 11.58min for SAT (difference: -5.45min; 95% CI: -8.27, -3.02min; p<0.001). Mean time to first meaningful pain relief was 13.34min for methoxyflurane and 27.38min for SAT (difference: -14.03min; 95% CI: -19.01, -9.06min; p<0.001). Patient satisfaction (scored out of 10) was significantly greater for methoxyflurane than SAT for efficacy (difference: 1.19; 95% CI: 0.59, 1.80; p<0.001) and comfort (difference: 0.77; 95% CI: 0.00, 1.54; p=0.05), and similar for safety. Methoxyflurane exceeded patient/clinician expectations of treatment in 73%/67% of cases compared with 45%/28% for SAT. Adverse events were reported for 31 (35%) methoxyflurane-treated patients (mainly dizziness) and 5 (7%) SAT-treated patients.

 

Conclusions

Methoxyflurane may be considered as an easy-to-use, rapid-acting, first-line alternative to opioid and other analgesic treatments for patients experiencing severe trauma pain.

Cesareo FERNÁNDEZ ALONSO, Sergio GARCÍA COLLADO, César CARBALLO CARDONA, Rosa CAPILLA PUEYO, Ignacio PÉREZ TORRES , Pere LLORENS SORIANO , José Ramón CASAL CODESIDO , María ARRANZ BETEGÓN , Luis AMADOR BARCIELA , Aitor ODIAGA , Anselma FERNÁNDEZ TESTA , Jorge TRIGO COLINA , Antonio CID DORRIBO , Isabel LÓPEZ ISIDRO , Susana TRASEIRA LUGILDE (Madrid, SPAIN), Alberto M. BOROBIA PÉREZ
15:55 - 16:00 #18809 - SP091 Prognosis value of geriatric trauma outcome score in senior severe trauma patients.
SP091 Prognosis value of geriatric trauma outcome score in senior severe trauma patients.

Background : Severe trauma is a life threatening situation and is widely described in young patients. Therefore, only few studies were interested in evaluating prognosis in senior trauma patients. Moreover, mechanisms of trauma in elderly  are not as so high velocity-related as in younger patients .This situation could expose to an undertriage of trauma. Fewer scoring tools were proposed in literature. The aim of this study was to evaluate the value prognosis of one Senior trauma score: Geriatric Trauma Outcome score ( GTO Score) to predict mortality at day 7 in aged severe trauma  patients

Methods : it was a prospective study with inclusion of trauma patients aged over 65 years. GTO score was evaluated. Prognosis value towards mortality at Day-7 was studied by characteristics of ROC curve.

Results:  A total of 65 patients was included from the cohort of 699 severe trauma patients admitted to the emergency department during the study period.  Characteristics of the population : mean age = 74 ± 6 years; Mean Injury Severity Score = 23 ± 15; Mean GTOS = 133 ± 38; need of vasocative agents n=16 (25%); massive transfusion in the first 24 hours n=2 (3%); Mortality rate was = 32 % ( n= 21) at Day 7. GTOS was statistically higher in non survivors compared to survivors senior patients : 160 ± 45 versus 120 ± 27 with p < 0,001. Characteristics of the ROC curve of GTO score to predict mortality at Day7 were: AUC = 0,790; p <0,001; CI[95%] = [0,667-0,913]; cut-off = 139; sensitivity = 71% ; negative predictive value 84% )

Conclusion : In this study, GTO score was predictive of mortality at day 7 post severe trauma in senior. Further comparisons with other specific scoring tools is whereas necessary to a better evaluation and emergency field application

Badr FERJEOUI, Imen MEKKI (Tunis, TUNISIA), Hamed RYM, Hana HEDHLI, Maaref AMEL, Rym BEN KADDOUR, Safia OTHMANI, Sarra JOUINI
16:00 - 16:05 #18913 - SP092 The incidence rate of death resulting from meningo cerebral lesions (LMC).
SP092 The incidence rate of death resulting from meningo cerebral lesions (LMC).

BACKGROUND

Considering the substantial number of death resulting from meningo cerebral lesions, we aimed to track the causes that led to these lesions and the number of death. These autopsies were performed at Medical Examiner Service( SJML) Sibiu between 2014-2018.

MATERIAL AND METHODE

The current retrospective research is made on a total of 1814 autopsies, performed at SJML Sibiu, between the period of 1 january 2014 – 31 December 2018. From this total, 243 had meningo cerebral lesions.

 

RESULTS

From a total of 1814 autopsies, performed at SJML Sibiu, the number of meningo cerebral lesions was 243, which represents 13,39 %, being distributed as follows: in 2014- 53 patients (21,82%), in 2015- 45 patients (18,51%), in 2016- 46 patients (18,93%), in 2017- 49 patients (20,16%) and in 2018- 50 patients(20,58%).

From these medical situations 104 (42,80%) came from the urban area and 139 (57,20%), from the rural area, and in terms of their gender distribution: 179 (73,66%) are man and 64 (26,34%) women.

During the study, patients with LMC was divided into aged groups as follows: 8 (3,30%) < 18 years, 72 (29,60%)- 19-39 years-, 101(41,57%)- 40-59 years-, 46 (18,93%)- 60-79 years-, 16 (6,60%) >80 years.

During the study, the causes that led to these lesions were: road accident - 103 (42,40%), railway accident- 18 (7,40%), forest accident – 11 (4,52%), falling out from the same level or height - 82 (33,75%) and aggression- 29 (11,93%).

 

CONCLUSIONS

Our research based on a 5-years period of study reveals that the number of patients with LMC during the autopsy in significantly higher to men compared to women and the number of rural patients is predominant.

Most patients fall into age groups: 19-39 (29,60%) and 40-59 (41,57%).

Most frecvently causes that led to LMC are road accidents and falling out from the same level or height.

The number of death caused by LMC is from 2015-2018 in continuous growth.

Ramona Andreea GANEA (SIBIU, ROMANIA), Andreea GANEA , Raluca RUIAN , Adela FARAIAN, Denisa VINTILA

Tuesday 15 October

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EPOSTER 5.4
15:45 - 16:05

ePoster 5.4 - Short Oral Presentation - Screen 4

15:45 - 15:50 #18957 - SP093 New method to evaluate an oxygenation for emergency patients who cannot measure SpO2 at the scene.
SP093 New method to evaluate an oxygenation for emergency patients who cannot measure SpO2 at the scene.

Introduction: There are some critical ill patients who cannot measure oxygen saturation (SpO2) by pulse oximeter at the pre-hospital settings. For example, among emergency patients who were treated by emergency medical service (EMS)personnel of Osaka Municipal Fire Departmentin 2016,there were 3,571 patients who had urgent conditions judged by on-scene EMS personnel but did not have cardiopulmonary arrest (CPA), but the measurement of SpOat the scene could not be measured for 395 patients. On the other hand, the measurement of cerebral regional oxygen saturation (rSO2) during resuscitation has been recently paid to attention.

Purpose: To evaluate whether rSOcould be measured for these patients.

Materials and methods: We developed portable rSOmonitors (weighs 600 g and can be carried easily by hanging it around the neck) and equipped them in nine ambulances (There are 63 ambulances in Osaka City). We measured serial changes in cerebral rSOamong emergency patients who had urgent conditions judged by on-scene EMS personnel and could not be measured SpOat the scene from April 1st 2018 through March 31th 2019. “SpOcould not be measured at the scene” was defined as patients in whom SpOcould not be measured for at least 30 seconds from one finger and after attempting measurement on at least two or more fingers at the scene.

Results: During the study period, there were 14 patients who had evaluated serial changes in cerebral rSOwith incapable-measurement SpOwho had urgent conditions judged by on-scene EMS personnel but did not have CPAat the prehospital settings. In many cases, rSOvalues were lower than normal but stable. There are two cases, rSOvalue rose by the ventilation support of the EMS personnel. 

Discussions: Even when SpOcannot be measured, maintenance of a constant value of rSOsuggests that oxygen supply and demand in the brain are stable. Monitoring of cerebral rSOis very useful for EMS personnel under the condition EMS could not evaluate their effort for patient’s by SpO2.

Conclusions: We could measure serial changes in cerebral rSOamong 14 patients without the measurement of SpOat the scene. Our data suggest that pre-hospital monitoring of cerebral rSOmight be a new physiological monitoring for urgent patients during transport.

Sakai TOMOHIKO (Suita city, JAPAN), Shiozaki TADAHIKO, Tachino JOTARO, Takegawa RYOSUKE, Ohnishi MITSUO, Shimazu TAKESHI
15:50 - 15:55 #19064 - SP094 Time from Emergency Medical Service contact to neurosurgical admission for patients with spontaneous subarachnoid haemorrhage – a retrospective cohort study.
SP094 Time from Emergency Medical Service contact to neurosurgical admission for patients with spontaneous subarachnoid haemorrhage – a retrospective cohort study.

Background: Longer time to neurosurgical admission may increase mortality and morbidity for patients with spontaneous subarachnoid haemorrhage (sSAH).

We aimed to determine the time from first telephone contact to the Emergency Medical Services (EMS) in Copenhagen to admission to a neurosurgical department. Secondly, to determine if the absence of the textbook symptom “thunderclap headache” was a predictor for late admission.

Methods: This retrospective cohort study was performed in March 2019. From the Danish National Patient Register data were extracted 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, 2014 with a primary discharge diagnosis of sSAH. Medical record review was performed to verify diagnoses. Time of the emergency telephone call was extracted from the EMS-database. Predictors for late admission to the neurosurgical department were analyzed in a logistic regression model adjusting for age and sex. Time interval was reported as median with inter-quartile range (IQR) and range. Proportions and odds ratios (OR) were reported with 95% confidence intervals (CI). Late admission was defined as being above the median value.

Results: Of 262 patients admitted with sSAH, no information was found on admission pattern in 96 patients, 34 patients had been admitted via general practitioners, and one was excluded due to a non-transparent pattern of admission. Thus, 131 patients had called either the European emergency number 1-1-2 or the non-urgent medical help line in Copenhagen both operated by EMS Copenhagen.

Data on initial hospital arrival were available for 119 patients and information about neurosurgical admission was available for 124 patients. Data on symptoms at the time of contacting the emergency telephone line was available for the period May 1, 2011 thru December 31, 2013 for 98 of the 102 patients admitted through the EMS.

Median time from EMS contact to neurosurgical admission was 207.5 minutes (IQR 147-305, 37-5,634). Eighty-six (72.3%, CI: 63.3-80.1) patients were initially admitted to a hospital without neurosurgical facilities and secondarily transferred. For these patients, the median time from arrival at the referring hospital to neurosurgical admission was 186.5 minutes (IQR 128-328). In comparison, in a hospital with neurosurgical facilities, the corresponding time interval between arrival to the hospital and admission to the neurosurgical department was 85.0 minutes (IQR 73-111). Seventeen (17.4%, CI: 10.4-26.3) patients had presented to the emergency telephone line with thunderclap headache. The crude OR for late admission in the absence of thunderclap headache was 5.1 (CI: 1.3-19.3). Adjusting for age and sex, the OR was 4.66 (CI: 1.2-18.1), p=0.0259.

Discussion: We found a median time from initial EMS contact to neurosurgical admission of 207.5 minutes in patients with spontaneous subarachnoid haemorrhage. The absence of thunderclap headache was a predictor for late admission.

Asger SONNE (Copenhagen, DENMARK), Jesper B ANDERSEN, Vagn ESKESEN, Frans B WALDORFF, Freddy LIPPERT, Nicolai LOHSE, Lars S RASMUSSEN
15:55 - 16:00 #19111 - SP095 National Estimates of Marijuana-related Poison Center Calls.
SP095 National Estimates of Marijuana-related Poison Center Calls.

Background: Marijuana is one of the most frequently used illicit drugs in the United States (U.S.) with 7.3% of the population above 12 years of age reporting marijuana use in the past month. Several U.S. states have legalized and regulated the use of marijuana for recreational purposes. The objective of our study was to evaluate the trends in marijuana calls to the U.S. poison centers (PCs) since these regulatory changes were undertaken.

Methods: The National Poison Data System (NPDS) was queried for exposures to marijuana from 01/01/12 through 12/31/18 using the generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Marijuana reports from acute care hospitals (ACHs), emergency departments (EDs), and overall calls including the public were evaluated as a subset. Trends in marijuana 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: During the study, there were 49,268 toxic exposures to marijuana that were reported to the PCs. The frequency of marijuana exposures increased by 209.4% (95% CI: 202.5%, 216.5%; p<0.001), and the rate of exposures increased by 227.1% (95% CI: 193.8%, 265.9%; p<0.001). Of the total marijuana calls, the proportion of calls from ACHs and EDs decreased from 66.1% to 60.9%, with the percentage of calls from the general public increasing. Multi-substance exposures accounted for 59.2% of the overall marijuana calls and 70% of calls from ACHs and EDs. Approximately 15% of the patients reporting marijuana exposures were admitted to the critical care unit (CCU), with 9% of patients being admitted to a psychiatric facility. The residence was the most common site of exposure (83.4%). Cases were predominantly male (58.7%), with the most common age group being 13-19 years (27.1%). The reports for young children under 12 years of age (6.2% to 19%) and older adults above 60 years (3.5% to 7.6%) increased. Intentional abuse (48.1%) was the common reasons for exposure, with the proportions of suspected suicides being higher in cases reported by ACH (20.3% vs 26.9%). During the study period, the proportion of reported marijuana abuse exposures decreased (50.3% to 35.3%), while unintentional exposures increased (11.4% to 22.4%). Major effects were seen in 5.6% cases and there were 223 deaths reported, with 10 fatalities reported for single substance marijuana exposures. The most frequently co-occurring substances associated with the cases were alcohol (16%) and benzodiazepines (15.7%).  Tachycardia (27%) and agitation (17.5%) were commonly observed clinical effects.

Conclusions: Our study results demonstrate a significant increase in the reports of marijuana exposures made to the PCs. The timeline of this study coincides with changes in federal and state laws regarding medical or recreational marijuana use in many states. The exposures in the adolescent age group increased which might be attributed to the unsafe storage practices of adults. Continued surveillance and public health prevention efforts are key to track the population effects of marijuana legalization.  

Saumitra REGE (Charlottesville, VA, USA), Marissa KOPATIC, Heather A. BOREK, Christopher HOLSTEGE
16:00 - 16:05 #19342 - SP096 How do We manage Superficial Venous Thrombosis? Altamira Study: Observational study in Spanish Emergency Departments.
SP096 How do We manage Superficial Venous Thrombosis? Altamira Study: Observational study in Spanish Emergency Departments.

BACKGROUND

Traditionally, superficial venous thrombosis (SVT) has been considered a benign disorder. It is known that it shares risk factors with deep venous thromboembolic disease (VTE) and therefore a risk of serious thromboembolic complications. There is no an homogeneus consensus in the diagnostic and therapeutic management of patients with SVT. Our objective was to describe the characteristics of patients diagnosed with SVT and their management in the emergency departments (ED) of Spain.

METHODS

Multicentric, retrospective, observational study with all patients diagnosed of SVT, during the period between January 2016 and May 2017 in 18 spanish ED.

Inclusion criteria were patients with diagnosis in ED of SVT in lower limbs, excluding those who presented an indication for anticoagulant treatment for any other pathology.

 The collected variables were demographic, characteristics of patients, comorbidity, VTE risk factors and the diagnostic and therapeutic management in the ED. Also, we collected any complication (recurrence or extension of SVT, deep venous thrombosis (DVT) or pulmonary embolism (PE)), haemorrhage or death in the next six months after SVT. In order to identify independent variables related to the decision of perform an ultrasound and prescribe anticoagulation by the physician, a multivariate analysis was carried out.

RESULTS

A total of 1202 patients were recruited, 67.4% of them women. The mean age was 59.55 ± 16.85, 24.5% had previous VTE, 4.6% active cancer, 2.4% a BMI> 30, and 50% had a history of varicose veins in lower limbs. 39.4% had hypertension and 26.5% diabetis. The median number  days of symptoms was 4 days (interquartile range (IR) 2-7), 50.7% had signs of SVT, being painful cord the most frequent (50.4%). 13.6% had symptoms of DVT. Only 0.5% had clinical symptoms of pulmonary embolism (PE). Only 56.7% underwent ultrasound. 927 patients (77.1%) received anticoagulant treatment with a median of 22 days (RI 10-30). Enoxaparin was the most used, 79.3%. 9.1% suffered a complication in the first six months, being SVT recurrent the most frequent (4.6%). The median number of days to complication was 77 days (RI 19-153). 84.3% had received anticoagulant treatment at diagnosis but only 22% were on anticoagulant treatment at the time of complication. The independent variables associated with the anticoagulation decision were previous VTE [OR 1.5 (95% CI (1.082-2.255); p <0.014)], history of varicose veins [OR1.440 (95% CI (1.079-1.920); p <0.013 )], SVT signs [OR1.42 (95% CI (1.059-1.882), p <0.018)], limb pain [OR1.572 (95% CI (1177-2.098), p <0.002)] and the performance of doppler ultrasound [OR2.241 (IC95% (1680-2988), p <0.001)].

CONCLUSIONS

SVT has an important incidence of complications. The diagnostic and therapeutic management is heterogeneous. The present study evidences that 84% of the patients with complication had received anticoagulant treatment, but 22% remained on anticoagulation at the time of the complication. The duration and/or intensity of anticoagulation for SVT patients in real clinical practice might be suboptimal. 

Fahd BEDDAR (Spain, SPAIN), Sonia JIMENEZ, Jose Maria PEDRAJAS, Lorena CASTRO, Marta MERLO, Ana María PEIRÓ, Angel ALVAREZ, Laura LOZANO, Angel SANCHEZ, Pedro RUIZ

Tuesday 15 October

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EPOSTER 5.5
15:45 - 16:05

ePoster 5.5 - Short Oral Presentation - Screen 5

15:45 - 15:50 #18003 - SP097 The modified bougie as conduit to magnet guided intubation optimized with industrial grade materials performed on cadaveric specimen.
SP097 The modified bougie as conduit to magnet guided intubation optimized with industrial grade materials performed on cadaveric specimen.

Background: We show further evidence for clinical utility of the modified bougie as a conduit for magnetic intubation.  This technique has been demonstrated in theory, subsequently optimized with industrial grade materials on an airway mannequin.  We presented preliminary work at the 2018 European Society for Emergency Medicine 12th Congress. The purpose of this study is to advance understanding through application of the same technique and equipment on four cadaver specimens. 

Methods: We obtained the following: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Hillman Group Ook 18 Guage Steel Galvanized Wire, DdFeB, Grade N52 DISC Magnet NiCuNi Plating Magnet to a Steel Plate: 377.6 Pound Pull Force, 2 dia x 2 thk (in), MAC blade laryngoscope, standard trauma shears, four cadaveric cephalus and torso specimens.  We used shears to cut the bougie at the 55 mark.  The guide wire was fully inserted.  Anatomy was visualized with the MAC blade.  The magnetic field was applied to the distal bougie in the cadaveric oropharynx and hypopharynx with navigating magnet via a location anterior to the cadaver neck.  We confirmed anatomic location via fluoroscopy and sensation of tracheal rings. 

Results: Magnet assisted anterior navigation of the bougie coude tip was obtained in the hypopharynx facilitating passage through the vocal cords into the trachea of each cadaveric specimen.  We replicated prior experience with this magnetic intubation technique on a mannequin in four cadavers.

Conclusion: The authors’ understanding of this unique magnetic intubation technique with industrial products has expanded beyond prior theory and use in the mannequin.  Inability to control the coude tip of the bougie as an adjunct tool for the difficult airway increases the likelihood of surgical airway.  Application of a magnetic field to control endotracheal instrumentation could be a useful tool in the difficult airway algorithm through expansion of existing device functionality.  Successful application in this limited sample of four cadavers suggests further study is important to better understand the magnetic intubation technique and its potential for future clinical utility.

Matthew VASEY (Tampa, USA), Tiffany VASEY, Angus JAMESON, Derek PUPELLO
15:50 - 15:55 #18674 - SP098 Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardio-pulmonary resuscitation: A sub-study of the CAAM trial.
SP098 Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardio-pulmonary resuscitation: A sub-study of the CAAM trial.

Purpose

Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP.

 

Methods

Adult patients from the CAAM trial that survived beyond 12 hours of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary outcome was the incidence of EOP in the BMV and ETI group. Variables related to morbidity were tested using a Principal Component Analysis (PCA) and a Partial Least Squares (PLS) analysis.

 

 

Results

Of 649 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 hours and thus included. Patients in the BMV group had a significantly longer period of time with an unsecured airway. No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 27%, ETI: 32%, Odds Ratio 1.2 [0.8-1.9], p=0.33). In the PCA analysis, we were unable to identify any morbidity variables that differed according to allocation. The PLS analysis revealed poor discrimination between the BMV and ETI group with an area under the curve of 0.54.

 

Conclusion
In this substudy of the CAAM trial, development of EOP in out-of-hospital cardiac arrest survivors did not seem to depend on airway management technique during CPR.

 

Josefine BAEKGAARD (Copenhagen, DENMARK), Mohamed TRIBA, Morgane BRANDEIS, Jacob STEINMETZ, Judith GORLICKI, Lars S. RASMUSSEN, Sandrine DELTOUR, Frederic ADNET
15:55 - 16:00 #18901 - SP099 QIP- Procedural Sedation in ED.
SP099 QIP- Procedural Sedation in ED.

Objectives

To implement in ED Procedural Sedation RCEM guideline in order to improve patient’s safety. The first audit was  completed over the  period from 19th of November 2018 to 31st of january 2019, results from documentation pre-procedure, procedure and post-procedure being calculated. The necessity of this QIP arose when an 2017 Audit regarding documentation of procedural sedation in our department  revealed non-compliance with RCEM guideline regarding this procedure.As part of this project, A File for"Procedural Sedation" was set up in Resus containing: RCEM guideline for procedural sedation, a new designed Sticker to be applied on the front page of the patient's notes with inscription "Procedural sedation", a table for patients details for auditing, 3xpages booklet to be completed with patient assessment(airway assessment ,fasting status,etc), patient's consent, vital signs of the patient, pre and post-procedure leaflet to be given to the patient. nasal capnography set up in Resus airway trolley. Monthly teaching performed in order to promote this project.

Results                              

From 33 patient who should have had procedural sedation, 16 patients had the procedure.Documentation improved from 0% to 48.48%. From the patient with documented pre-procedure, improvement were found in: ASA documentation(from 0% to 75%), prediction difficult airway(from 0% to 87.5%), documentation fasting status(from 0% to 68.75%), documentation informed consent (from  37% to 100%), pre-procedure leaflet given( from 0% to 100%),; documentation procedure in Resus(from 46% to 75%), documentation staffing performing the procedure(from 0% to 87.5%), documentation capnography ( from 0% to 12.5%), when oxygen was given( from 0% to 25%),  post-procedure leaflet (from 0% to 62.5%), documentation discharge suitability( from 0% to 37.5%).

Discussion

It is room for improvement for documentation oxygen time / quantity administered, capnography monitoring, documentation discharge suitability, which will be recorded on the second audit in progress.

A second audit is in progress at the moment. Because the usage of the nasal capnography is not satisfactory, teaching regarding the capnography usage was attached to the monthly teaching for this project. The final QIP presentation  will use a PDSA( Plan-Do-Study-act) model for improvement, measuring the documentation of the pre-, post and procedural patient's management. A Gunt and Run charts will be calculated at the final writing paper of this project. 

At the moment a Poster is planned to be placed in RESUS with pictures of the File and capnography and a meeting with a second speciality is in place, in this context Anaesthetics, in order to seek for help in managing the airway for Procedural sedation Project.

Nicoleta CRETU (Lincoln, UK), Megan KELLY
16:00 - 16:05 #19248 - SP100 Prognostic value of leukoglycemic index in acute exacerbation of chronic obstructive pulmonary disease: A prospective observational study.
SP100 Prognostic value of leukoglycemic index in acute exacerbation of chronic obstructive pulmonary disease: A prospective observational study.

Background: Several biological markers are used to predict poor outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Each of Glycemia and white blood count are known as predictive factors of poor outcomes in AECOPD. The combination of the two could have more sensitivity and specificity value ; The aim of our study was to evaluate the prognosis value of leukoglycemic index( LGI )in patients admitted to the emergency department (ED) with AECOPD.
Methods: Prospective observational study over one year. Inclusion of patients admitted to the ED with AECOPD. The primary endpoints were the need for mechanical ventilation (MV), and 30-day mortality. Test performance was assessed using the area under the receiver operating characteristic curve.

Results: 120 patients were enrolled. Mean age was 63 +/-8 years. Men n (%) was 64 (52, 9). Mean LGI was 12, 10 +/- 7, 14. The LGI area under the receiver operating characteristic ( ROC ) curve (AUC) for the use of (MV) and for the one –month mortality were respectively: 0,74 ;p=0,01;IC 95% [0,58- 0,90] and 0,83;p=0,000; IC 95% [0,69- 0,96]. The best prognostic cut-off value for LGI was 8. In univariate analysis LGI > 8 was associated to 2.1 threshold risk of MV (p=0.001; IC 95% [1.386-3.528] and 4.4 threshold risk of death (p=0.001; IC 95% [1.497-8.839]).
Discussion & Conclusions:
Despite the relatively small number of patients and the fact that the study was conducted only at one hospital, our findings might assist the risk stratification
of AECOPD in the ED, contributing to a better management .At the same time, further medical complications as a result of downgrading the risk of patients with AECOPD in the ED could also be avoided. The LGI is a good prognostic index easy to calculate with a good prognostic value . It can predict poor outcomes during the acute exacerbation.

Hadil MHADHBI (TUNIS, TUNISIA), Khédija ZAOUCHE , Yosra YAHYA , Abdelrahim ACHOURI, Abdelwaheb MGHIRBI , Hamida MAGHRAOUI, Radhia BOUBAKER, Kamel MAJED
Wednesday 16 October
10:15

Wednesday 16 October

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EPOSTER 6.1
10:15 - 10:35

ePoster 6.1 - Short Oral Presentation - Screen 1

10:15 - 10:20 #18116 - SP101 Assessment of the management of acute cholecystitis diagnosed in an emergency department of a French University Hospital.
SP101 Assessment of the management of acute cholecystitis diagnosed in an emergency department of a French University Hospital.

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.

Mélissa FLEURY, Farès MOUSTAFA (Clermont-Ferrand), Nicolas DUBLANCHET, Marie THOMAS, Mathilde QUINTY, Sonia AJIMI, Marine MONDET, Jeannot SCHMIDT
10:20 - 10:25 #18127 - SP102 Pregnancy outcome following bacteriuria in pregnancy and the significance of nitrites in urinalysis - A retrospective cohort study.
SP102 Pregnancy outcome following bacteriuria in pregnancy and the significance of nitrites in urinalysis - A retrospective cohort study.

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 20st 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.

Shachaf SHIBER (Tel aviv, ISRAEL), Irit AYALON-DANGUR , Naamany EVIATAR , Drescher MICHAEL
10:25 - 10:30 #18538 - SP103 “Early prediction of mortality based on predisposition, qSOFA and renal function in patients admitted to the Emergency Department with a diagnosis of pneumonia: a prospective study”.
SP103 “Early prediction of mortality based on predisposition, qSOFA and renal function in patients admitted to the Emergency Department with a diagnosis of pneumonia: a prospective study”.

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.

Livio COLOMBO (Milan, ITALY), Simone PASINI, Piera PUGLIESE, Silvia COLOMBO, Greta ROSSIGNOLI, Elena CLERICI, Irene RUSCONI, Alfredo MACHEDA, Fabia CASTAGNA, Federica BIANCHI, Adele Anita RADICI, Pier Maria BATTEZZATI
10:30 - 10:35 #18747 - SP104 Impact of implementation of a rapid influenza Point of Care Testing (POCT) in the Emergency department (ED).
SP104 Impact of implementation of a rapid influenza Point of Care Testing (POCT) in the Emergency department (ED).

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.

Christelle HERMAND (PARIS), Narjis BOUKLI, Aurélie SCHNURIGER, Nicolas CURY, Youri YORDANOV

Wednesday 16 October

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EPOSTER 6.2
10:15 - 10:35

ePoster 6.2 - Short Oral Presentation - Screen 2

10:15 - 10:20 #18114 - SP105 Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.
SP105 Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.

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.

Alexis COURNOYER (Montréal, CANADA), Sylvie COSSETTE, Brian POTTER, Raoul DAOUST, Luc DE MONTIGNY, Luc LONDEI-LEDUC, Yoan LAMARCHE, Dave ROSS, Judy MORRIS, Jean-Marc CHAUNY, Catalina SOKOLOFF, Jean PAQUET, Martin MARQUIS, Martin ALBERT, Francis BERNARD, Massimiliano ISEPPON, Éric NOTEBAERT, Yiorgos Alexandros CAVAYAS, André DENAULT
10:20 - 10:25 #18239 - SP106 High-flow nasal cannula versus low oxygen flow therapy in weaning from non-invasive ventilation in patients with acute respiratory failure due to COPD exacerbation: a subICU experience.
SP106 High-flow nasal cannula versus low oxygen flow therapy in weaning from non-invasive ventilation in patients with acute respiratory failure due to COPD exacerbation: a subICU experience.

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.

Francesca NORI (Cesena, ITALY), Stefano GENIERE NIGRA, Marina BUDA, Giacinto PIZZILLI, Annalisa DE SILVESTRI, Patrizia CUPPINI, Alessandro VALENTINO
10:25 - 10:30 #19010 - SP107 Interaction effect between mechanical chest compression device use and post cardiac arrest care on survival outcomes after out-of-hospital cardiac arrest.
SP107 Interaction effect between mechanical chest compression device use and post cardiac arrest care on survival outcomes after out-of-hospital cardiac arrest.

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.

Hyunho RYU (gwangju, KOREA)

Wednesday 16 October

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EPOSTER 6.3
10:15 - 10:35

ePoster 6.3 - Short Oral Presentation - Screen 3

10:15 - 10:35 #18927 - SP109 Emergency department nurses can safely remove cervical collars in low risk adult trauma patients: a systematic review of literature.
SP109 Emergency department nurses can safely remove cervical collars in low risk adult trauma patients: a systematic review of literature.

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.

Arianna GAZZATO, Tommaso SCQUIZZATO (Milan, ITALY)
10:15 - 10:35 #19060 - SP110 Are we providing appropriate advice to patients discharged post head injury?
SP110 Are we providing appropriate advice to patients discharged post head injury?

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. 

Christopher KELLY (Glasgow, UK)
10:15 - 10:35 #19162 - SP111 COST ANALYSIS OF TRAFFIC ACCIDENTS IN WINTER SEASON THROUGH ANATOMIC SCORING.
SP111 COST ANALYSIS OF TRAFFIC ACCIDENTS IN WINTER SEASON THROUGH ANATOMIC SCORING.

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.

Dilek ATIK, Burçe KOÇKAN, Bensu BULUT, Hilmi KAYA, Ramiz YAZICI, Ramazan GÜVEN (ıstanbul, TURKEY), Başar CANDER
10:15 - 10:35 #19287 - SP112 Epidemiology and Outcomes of Acute Kidney Injury in an Irish Trauma Population.
SP112 Epidemiology and Outcomes of Acute Kidney Injury in an Irish Trauma Population.

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. 

 

Filip LIS, Owen KEANE, John CRONIN (Dublin, IRELAND)

Wednesday 16 October

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EPOSTER 6.4
10:15 - 10:35

ePoster 6.4 - Short Oral Presentation - Screen 4

10:15 - 10:20 #18132 - SP113 Theatre of the oppressed: empowering emergency staff.
SP113 Theatre of the oppressed: empowering emergency staff.

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. 

Christina Lalani HANDALAGE, Hajela SAPNA, Javadian PARISA, Edmundson HEIDI (London, UK)
10:25 - 10:30 #18794 - SP115 Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.
SP115 Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.

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.

Tuukka TOMMINEN (Hämeenlinna, FINLAND), Ville HÄLLBERG, Ilkka VARTIAINEN, Topi MATTILA, Shu ALEX , Ari PALOMÄKI
10:30 - 10:35 #19007 - SP116 In pursuit of the most efficient technique of improving feedback skills among emergency medicine residents- a randomized controlled trial.
SP116 In pursuit of the most efficient technique of improving feedback skills among emergency medicine residents- a randomized controlled trial.

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.

Khalid BASHIR (Doha, QATAR), Amr Mohammed Abdallah ELMOHEEN, Mohamed Ahmed SEIF MOHAMED, Saleem FAROOK, Shahzad ANJUM, Kodumayil ASHID , Kumar THIRMOOTHY SAMY SURESH, Thomas PROF. STEPHEN

Wednesday 16 October

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EPOSTER 6.5
10:15 - 10:35

ePoster 6.5 - Short Oral Presentation - Screen 5

10:15 - 10:20 #18498 - SP117 Non-invasive Zip wound closure for lacerations in pediatric and adult A&E departments.
SP117 Non-invasive Zip wound closure for lacerations in pediatric and adult A&E departments.

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.

Filippa LINDÉN BERGMAN (Stockholm, SWEDEN), Anna DAHL, Christian SCHYLLERT, Ellinor MAGNUSSON, Emmanuele PATTI, Jeremia JILKE, Felicia RYDEBERG KJAERNET, Margaretha LANNGE, Krakowski RADEK, Pia MALMQUIST, Therese DJÄRV
10:20 - 10:25 #18767 - SP118 Is trainee led research the future? Subarachnoid haemorrhage in emergency departments – a service evaluation of the UK trainee emergency research network.
SP118 Is trainee led research the future? Subarachnoid haemorrhage in emergency departments – a service evaluation of the UK trainee emergency research network.

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.

Tern TRAINEE EMERGENCY RESEARCH NETWORK, Tom ROBERTS (Bristol, UK), William HULME
10:25 - 10:30 #18984 - SP119 A conceptual framework for understanding value and waste in emergency department patient flow: a qualitative case study.
SP119 A conceptual framework for understanding value and waste in emergency department patient flow: a qualitative case study.

Background

Reducing waste and maximising value in ED patient flow is usually limited to reducing delays and accelerating activities. This assumes that all delays are wasteful and all activities valuable. However, value and waste should be determined from the customer perspective where the customer is anyone who uses something that is made or provided by a previous step in the patient process. The goal of this study is to identify value and waste in ED patient flow from a patient perspective, with clinicians acting as the patients’ agents. The inclusion of these two groups provides insight into where value and waste exist and allows for a comparison of perspectives. Including patients encourages their active participation and supports a collaborative approach to improving ED patient flow.

Methods

The study was conducted in a major hospital ED in Trinidad and Tobago, from May 2017 to March 2018. A single case study design was adopted, employing multiple qualitative methods. Observational process mapping (155 hours) and informal conversational interviews (90) were used to explore patient flow, value and waste. Data were collected in real time from patients and their agents, the doctors. Participants were selected using purposeful sampling. Patients were sampled from all levels of urgency based on the triage system. Doctors were sampled from all levels of seniority (consultants, registrars and house officers). Thematic analysis was used to create a framework on value and waste in ED patient flow.  Verbal consent was obtained from participants using an on-going opt out approach. The University of the West Indies Campus Ethics Committee gave formal ethical approval and permission to conduct the research in the ED site was granted by the hospital case study site.

Results

In total, 43 doctors and 47 patients were interviewed. The findings on value generated two overarching themes while those on waste generated three themes. Valuable aspects were those that led to direct improvements in the patient’s health or experience or led to an exchange of knowledge or information in the process. Wasteful aspects were those that delayed patient progression, did not lead to an exchange of knowledge or information or resulted in a perceived inappropriate use of the ED or doctor’s time. Overall, patients perceived waiting to be wasteful but doctors identified occasions where some waiting periods provided value.

Discussion and conclusion

This study has produced a framework for identifying value and waste in ED patient flow from a patient perspective with doctors acting as their agents. Although the framework should be validated in other settings, it is useful for providing a practical approach to improving ED patient flow by enabling departments to identify and reduce wasteful aspects and optimise valuable aspects of the process. Ultimately, the framework may be used to improve patient flow in a way that maximises value to patients.

 

Loren DE FREITAS (Trinidad and Tobago, TRINIDAD AND TOBAGO), Steve GOODACRE, Rachel O'HARA, Praveen THOKALA, Seetharaman HARIHARAN
10:30 - 10:35 #19387 - SP120 A Review of Management Neck of Femur Fracture Pathway in the Emergency Department.
SP120 A Review of Management Neck of Femur Fracture Pathway in the Emergency Department.

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.

 

 

Maeve LEONARD (Sligo, IRELAND), Ahmed AL RASHEED