Title: The development of Thailand’s hospital assessment instruction and evaluation for mass casualty incident and disaster preparedness

Introduction: Community preparedness is the key component to mitigate the effects from mass casualty incident (MCI) and disaster. The hospital awareness and preparedness is one component of MCI and disaster preparedness in the community as it plays a critical role in taking care of injured patients. To improve hospital preparedness for MCI or disaster management, the first requirement is to assess the current system capacity, readiness, awareness and preparedness. Nevertheless, there is no assessment tool that is appropriate for Thai hospitals and the Thailand context.

Objective: To develop a hospital MCI and disaster preparedness assessment tool for hospitals in Thailand

Material and methods: A systematic search was done of available literature in English and Thai languages published up to 31 December 2014 in various databases: Pubmed, Medline (Ovid), Cochrane library (Wiley), Cinahl (Ebscohost), Embase (Elsevier), World Health Organization (WHO) guidelines and other organizations. The search used the key words ”assessment,” “evaluation,” protocol,” “hospital preparedness,” “thesis,” and “full report.” These terms were combined with disaster or mass casualty-related keywords. The enrolled articles were assessed, and information was extracted independently by three reviewers. The assessment tool was developed by using a modified Delphi method and the WHO health systems (six building blocks plus) framework, expert inputs, public hearing, stakeholders’ inputs, and a pilot feasibility test.

Results: There were 5,869 total articles identified; 5,593 articles irrelevant to medicine or public health and 183 articles not related to hospitals were excluded. The remaining 76 full articles (8/76 (10%) with an assessment tool) were enrolled for analysis and  data and information were extraacted. A new assessment tool was developed independently by three reviewers and finalized in a joint reviewer meeting. The tool is composed of 4 parts; general information, 127 assessment items, suggestions, and hospital actual and surge capacity. All inputs obtained from experts, public hearing, stakeholders meeting, and pilot feasibility test were used to revise the tool.

Conclusion: The hospital assessment tool was developed to evaluate level of preparedness of Thai hospitals for MCI and disaster.

Faculty of Medicine, Prince of Songkla University

Background:

Previous studies have found an association between high hospital bed occupancy and increased mortality among patients admitted to hospital. We aimed to evaluate the importance of bed occupancy for adverse outcomes among all patients visiting the emergency department (ED).

Methods:

Adults visiting six EDs in Stockholm County, Sweden, from 2012 to 2016 were categorized into groups by bed occupancy: < 85%, 85%–89% (reference group), 90%–94%, 95%–99%, 100%–104%, and > 104%. Cox regression was used to estimate adjusted hazard ratios (HR) with 95% confidence intervals (CI) for 30-day mortality, in-hospital mortality, readmission for inpatient care within 30 days of hospital discharge, and revisits to the ED within 7 days.

Findings:

A total of 816,832 patients with 2,084,554 visits were included in the analysis. Mean bed occupancy was 93·3%. In total, 28,112 patients died within 30 days (1·3% of visits), and 17,966 patients died in hospital (3·9% of admissions). Bed occupancy was not associated with 30-day mortality or with in-hospital mortality, although increased adjusted point estimates indicated associations of bed occupancy > 104% with 30-day mortality (HR = 1·10, 95% CI: 0·96–1·27) and with in-hospital mortality (HR = 1·09, 95% CI: 0·92–1·30). High bed occupancy led to an increased length of stay in the ED and a reduced admission rate for inpatient care.

Interpretation:

Our findings indicate that health care staff are able to prioritize correctly without compromising patient safety at high bed occupancy, despite increased lengths of stay in the ED and a decline in admissions for inpatient care. However, we believe that practitioners should aim for a bed occupancy < 105%, given our observation of a trend towards higher mortality at ≥ 105% bed occupancy. Preparedness to reallocate resources to the ED is needed when bed occupancy increases because the workload is likely to rise even when bed occupancy is at 85%.

This study was funded by a grant from Sjukhusläkarna.

Background: Violence against healthcare workers (HCWs) is increasing and Emergency Departments (EDs) frequently face with daily violence occurrence, with staff reporting several episodes each week. Literature shows that HCWs are considered most at risk of aggressive actions, but in Italy there are no consolidated statistics on the spread of the phenomenon, despite the fact that in recent times it is constantly being placed at attention through the media. Recently it has been deemed necessary to detect the episodes of aggression in the Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona (I).

Methods: Starting from the Violent Incident Form (VIF) of Arnetz, a HCWs dedicated self reporting form is accessible 24/24 in our intranet.

Results: data refer to the episodes of aggression reported by HCWs of the AOUI - Verona in 2016-2018 years with reports increasing from 3 to 27 and 66 respectively. Most of the aggressions were by patients (2016: 33%; 2017: 77%; 2018: 73%) or relatives (2016: 67%; 2017: 15%; 2018: 20%) but also colleagues (2017: 8%; 2018: 5%) involving men as aggressors (2016: 60%; 2017: 67%; 2018: 73%) and women as victims (2016: 67%; 2017: 58%; 2018: 73%), mostly paramedics (2016: 100% nurses; 2017: 81% nurses, 11% physicians and 11% health worker; 2018: 82% nurses, 12% physicians and 6% health worker). In most of the cases the aggressor was in age group 18-30 (2017: 30%; 2018: 17%), 31-50 (2016: 67%; 2017: 41%; 2018: 48%) or 51-65 (2016: 33%; 2017: 19%; 2018: 20%) years. The preponderant percentage of the personnel attacked was in 50-59 years age group (40%) in 2018, slightly different from 2016 and 2017 prevalence of 40-49 years  (2016:100%; 2017: 37%). Aggressions were mostly during routine activities or normal conversation (2017: 27%; 2018:38%) and following clarification requests (2017: 33%; 2018: 14%). Took place in wards spaces (2016: 33%; 2017: 48%; 2018: 23%) or in patient's room (2016: 33%; 2017: 26%; 2018: 23%), in the morning (6.00-9.00; 2017: 19%; 2018: 12%), between 12.00 and 18.00 (2016: 66%; 2017: 41%; 2018: 44%) and in the evening (21.00-24.00; 2018: 15%). The workers felt the situation degenerate into violence (2017: 67%; 2018: 64%) and help was needed to stop the aggression (2016: 77%; 2017: 70%; 2018: 51%). The aggressors described as "mentally unstable" (2016: 67%; 2017: 64%; 2018: 24%) used verbal and physical violence. Reports from EDs workers are present only from 2018 (35% of cases).

Discussion and Conclusions: Despite an increasingly number of reports received, data do not reflect the real extent of the phenomenon in our agency. Moreover few reports were received from structures that the literature identifies as having a high risk of aggression, such as the EDs are. This could be explained by poor information about the aggression reporting form accessible in the intranet. Aggressive behaviours are perpetrated by particularly fragile and vulnerable subjects, leading to a widespread tendency to justify aggressive actions. Increasing awareness and reporting of the phenomenon and strategies to recognize and manage aggressions is the next great challenge.

This research received no external funding. The authors declare no conflict of interest.

Background: In the primary care setting such as the emergency department, highly accurate biomarkers are important in diagnosing acute illnesses such as acute myocardial infarction (AMI). In order to quickly and more accurately achieve the diagnosis and disposition, high-sensitive troponin assays have emerged for this decade. We aimed to compare the performance of conventional and different novel high-sensitive troponins. 

Methods: We conducted this observational retrospective cohort study using the existed record as well as waste specimen testing in a tertiary teaching hospital in Taiwan. Utilizing text-mining method to retrieve all patient-visits with symptoms suggestive of an acute coronary syndrome (ACS) with troponin test in the electronic medical record (EMR), we operationally defined AMI using free-text of discharge diagnosis and the ICD-9 and 10 codes. We further utilized the waste specimen to test platforms from Roche, Abbot, and Beckman for the performance of HsTnT and HsTnI. We use the algorithm recommended by the Taiwan society of emergency medicine to categorized patients into subgroups including rule-out, rule-in, and observation. Specific cut-offs for the elderly (> 70 years), different genders and impaired renal function (eGFR<60) were obtained from the manufacture and the literature. The performance of different tests was evaluated by AUROC, sensitivity, specificity, NPV, and PPV.

Results: We included 97,183 patients presenting to ER with symptoms suggestive of ACS and test of troponin from 2006 to 2018. Around 9.5% admission with acute myocardial infarction(n=9,194) were identified through this process. HsTnT outperformed the conventional TnI in our cohorts (overall AUROC: 0.81 vs. 0.71, Sensitivity: 76.83% vs. 30.97%, Specificity: 61.04% vs. 82.54%, PPV: 21.95% vs. 13.43%, and NPV: 94.87% vs. 93.19%, respectively). However, level of HsTnT was more likely to be influenced by age and renal function. We further tested 319 waste specimens out of 143 patients to compare different HsTn plateforms. Accordingly, HsTnT seemed to outperform HsTnI (AUROC 0.833 vs. 0.743, p=0.02, Sensitivity: 76.83% vs. 100%, Specificity: 61.04% vs. 48.21%, PPV: 21.95% vs. 19.44%, and NPV for rule-out: 94.87% vs. 100%, NPV for observation: 92.17% vs.81.58%, respectively. Using different HsTn cutoffs for the elderly, we observed increased PPV for Roche (from 21.95% to 25%) but decreased for Abbott and Beckman (from 20% to 15.79% and from 19.44% to 8.3%). Using different HsTn cutoffs for genders, increased PPV of male (Roche: from 18.75% to 23.81%, Abbott: from 20% to 29.17%, Beckman:f rom 19.44% to 27.27%) and much decreased PPV of female in all tests (Roche: from 18.75% to 5.56%, Abbott: from 20% to 5.26%, Beckman: from 19.44% to 7.69%) were observed. In terms of different cutoffs for impaired renal function, increased PPV of Roche (from 21.95% to 26.09%), Abbott(from 20% to 28.57%) and Beckman (from 19.44% to 19.5%) were observed.

Conclusion: In this observational study, we found the HsTnT provided almost two-fold higher PPV than TnI in diagnosing AMI in the ED. HsTnT seemed to outperform HsTnI. However, the differences between different HsTnI platforms were not significant. Nonetheless, this study is limited to the retrospective nature so the incorporation bias could not be avoided.

The study was supported by the Ministry of Science and Technology (Taiwan) and Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Background: Accurate prognostic assessment of septic patients is challenging in the emergency department (ED). Identification of patients at high risk of organ failure or shock could help to prevent deterioration and reduce mortality. Clinician’s assessment is based on initial severity, scoring, social context, hospital bed capacity, and on personal experience. The performance of emergency physicians in predicting septic patient’s outcome has been scarcely described, and the additional value of a prognostic biomarker has not often been evaluated in the ED. Therefore, we calculated the prognostic performance of emergency physicians to predict clinical deterioration of septic patients during their initial management in the ED and evaluated whether adding biomarkers information could improve this clinical prediction.

Methods: This is an ancillary study of the TRIAGE study (ClinicalTrials.gov: NCT02739152) designed to evaluate a panel of prognostic endothelial biomarkers (sVEGFR2 and sUPAR) in a cohort of adult septic patients admitted to the ED. The analysis was performed on non-severe patients (SOFA<2) of two teaching hospitals. The risk of clinical deterioration was assessed by an adjudication committee composed of three independent emergency physicians (blinded from deterioration outcome) according to the emergency medical records and the first conventional biological and imaging results. This first judgement allowed calculating the clinical emergency physician’s performance. Then, adjudicators were unblinded from the results of biomarkers (which helped classifying patients into two groups: “high risk” or “low risk”) and were asked to keep or revise their first judgement. This second judgement allowed assessing the additional value of biomarkers. Finally, the performance of biomarkers alone was calculated.

Results: Analyses were performed on 145 patients (age = 50±20 yr; Charlson score: 1.7 [0-3]; SOFA score: 0.5 [0-1]; lactates: 2.03 [1.17-2.41]; site of infection: pulmonary 12.4%, urinary 32.4%, abdominopelvic 34.5% and 30 patients deteriorated (21%). The clinical performance of emergency physicians to predict deterioration was: Sensitivity=80; Specificity=21; Negative Predictive Value=80; Positive Predictive Value=21. Adding the biomarkers improved the clinical prognostic performance of emergency physicians (Sensitivity=90; Specificity=19; Negative Predictive Value =88; Positive Predictive Value =23). Biomarker alone was the best predictor of deterioration (Sensitivity =93; Specificity =50; Negative Predictive Value =97; Positive Predictive Value =33).

Conclusion: This study confirms that predicting the clinical deterioration of septic patients in the ED remains challenging. Adding prognostic biomarkers (sVEGFR2 and sUPAR) to clinical evaluation could be helpful in early assessing the risk of deterioration of septic patients, and safely ruling out patients after ED admission due to its high negative predictive value.

ClinicalTrials.gov: NCT02739152

Background

Acute infections are one of the major reasons patients present to the Emergency Department (ED). An acute infection may lead to sepsis, a life-threatening condition. Identifying the infected or septic patient is a crucial task because accurate diagnosis and rapid treatment both have a massive effect on the prognosis. The Intensive Care Infection Score (ICIS) is a novel biomarker, already established for ICU patients, which displays the activity of the innate immune response. The ICIS is based on automated blood cell count, which makes it fast, easily accessible and low cost. Here we evaluated the ability of ICIS to identify the infected and/or septic patient presenting to the ED.

 

Method

In a non-interventional prospective study, we enrolled potential septic patients with ≥2/4 criteria for systemic inflammatory response syndrome (SIRS) or/and ≥2/3 quick sequential organ failure assessment score criteria(qSOFA) presenting to the ED. 222 patients were enrolled and received a microbiological screening for a pathogen causing the altered SIRS or qSOFA criteria.  ICIS and C-reactive protein (CRP) were compared in predicting a microbiological proof of infection and the decision for antibiotic treatment.

 

Results

The area under the receiver operating characteristic curve (AUROC) for the prediction of infection (positive culture or indirect proof of a bacterial infection) for ICIS was 0.76 (95% CI: 0.70–0.82), compared to CRP 0,75 (CI: 0.69–0.82). The AUROC for predicting the decision for an antibiotic treatment: ICIS 0.74 (95% CI: 0.68–0.81), CRP 0,78 (CI: 0.71–0.84).

 

Conclusion

The data show that compared to CRP, ICIS provides a similar ability to identify infections and to guide antibiotics. However, being less expensive and quicker in determination, ICIS may play a considerable role in the ED in the future.

 

 

 

 

 

 

 

 

This study did not receive any specific funding and was approved by the local Charité – Universitätsmedizin Berlin ethics committee, Ethics application no.: EA4/011/17.

Background: Coronary artery disease (CAD) is caused by vascular atherosclerosis together with persistent low-grade innate immune inflammation that plays a role in the initiation, progression, and destabilization of the atherosclerotic plaque. Triggering receptor expressed on myeloid cells (TREM)-1 is a novel member-bound receptor expressed on myeloid cells. Soluble TREM-1 (sTREM-1) reflects innate immune cell activation and its levels are significantly elevated in patients with well- established CAD as well as in acute coronary ischemic events. 

Aim: We seek to determine the plasma levels of sTREM-1 in acute coronary syndrome (ACS) and the association with the severity and 30-day outcome in patients who present with chest pain (CP) to the emergency department (ED).

Methods: We conducted a prospective, case-control study of 121 consecutive patients who presented to the ED with new-onset CP  (≤ 24 hours) suspected suffering of ACS, defined as CP with either ECG changes compatible with ST elevation MI (STEMI), non ST elevation MI (NSTEMI), unstable angina, or advanced angina pectoris. Patients with known inflammatory, infectious or neoplastic diseases were excluded. Patients were divided to 59 (48.7%) patients with ACS (59; 48.7%) and 62 (51.3%) patients with non-coronary CP (NCCP) groups according to the clinical, laboratory and ECG data. Final diagnosis and 30-days outcome were obtained.  Seventy-three age- and sex-matched healthy individuals served as a control group.  Blood samples were collected at the time of arrival to the ED and plasma samples were kept in -80°c until assayed for the level of sTREM-1 using a commercial ELISA kit. 

Results: Within the group of patients with CP, plasma sTREM-1 level was significantly higher in the ACS group compared to NCCP  (   432 + 23 vs. 292 + 56 pg/ml, p=0.03). In a multivariate analysis using Linear regression model, we found that plasma sTREM-1 level correlates  with ACS ( p= 0.001, 95% CI 92.2-360.2)  and smoking (p= 0.06, 95% CI 1.9-137.6) and with  elevated  creatinine ( p= 0.03, 95% CI 27.0-502.3). ROC analysis of plasma sTREM-1 level among ACS vs. NCCP  was AUC 0.703, 95% C.I 0.610-0.796 P<0.001, and in the group of STEMI/NSTEMI (n=30) vs. control  was AUC 0.842, 95% C.I 0.760-0.924 P<0.001.

Conclusions: Our data of elevated plasma sTREM1- level in ACS is in accordance to previous studies that suggest a role for innate immune activation, and more specifically TREM-1, in the evolution of ACS including MI. We suggest that plasma sTREM-1 might serve as a biomarker for the differentiation of ACS from NCCP in the ED.    

Shachaf Shiber 1, 2, 6 , Vitaly Klemiski 4, 6 , Katia Orvin 3, 6 , Iftach Sagy 1, 5 , Mordechai Vaturi 3, 6 , Yair Molad 1, 4, 6 1Rheumatology Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 2Emergency Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 3Cardiology Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 4Laboratory of Inflammation Research, Felsenstein Medical Research ,Petach Tikva, Israel 5Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel, 6Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction:Venous thromboembolic disease (VTE),which includes deep vein thrombosis (DVT) and pulmonary thromboembolism (PE), is the third most frequent cause of cardiovascular death, with an incidence of 1-2people/every1000, every year in the USA. The incidence of PE increases exponentially with age. Its diagnosis tends to pose a challenge for the emergency physicians because of the non-specific and heterogenic signs and symptoms. 

Most patients with PE usually have the following clinical significances:dyspnea,sudden onset,tachypnea,chest pain (usually substernal with pleuritic features). A differential diagnosis of pulmonary disorders has to be set out:pneumonia,exacerbation of chronic lung disease,cardiac disorders,musculoskeletal disorders or PE. In view of this characteristics,objective tests are needed to identify patients who are likely to have PE. For that,clinical prediction scales such as Wells' are necessary,taking into account the existence of previous VTE,recent surgeries or immobilization,cancer,hemoptysis,heart rate up to 100beats/minute,clinical signs of DVT or if there is an alternative diagnosis less likely than PE. It can stratify at low,moderate or high risk. According to the result,we will decide if it is necessary an imaging test,according to the calculated risk and the indication to measure the D-Dimer in blood.

Objective:Review the indications for requesting D-Dimer in patients who attend an emergency service and thus review the correct use of the clinical scales that predict the risk of suffering a PE, such as the Wells scale.

Method:Retrospective descriptive study of the patients who D-Dimer was requested, who attended the emergency department of a university hospital of third level, in a period between 1/1/2017 and 30/6/2017. A data collection sheet was made with the clinical and sociodemographic variables previously defined. Subsequently, the data was analyzed with the statistical package SPSS.

Results: During the period described, a total of 251DDimer were requested. 52% were men with a median age of 70years. Regarding the pathological background, 83.7% had history related to a possible increase in thromboembolic risk and 29.8% of patients had specific risk factors. The scale value of Wells was collected only in 1.3% of the medical reports. D-dimer request was indicated in 57.8% of the cases. Regarding risk stratification, 79.6% had low risk and 19.6% moderate risk to suffer VTE. The median score on the Wells scale was 1point. The D-dimer was positive in 60.8%, however when D-dimer was adjusted at age, it was positive in 46.8%.

Conclusions: As shown in the data obtained, a minimum percentage of the reports had collected the value of Wells or Geneva scale in order to stratify the risk. The evaluation of the probability of suffering VTE in a patient through clinical presentation is essential for the subsequent interpretation of complementary studies. Although, as has been demonstrated, VTE is not always suspected due to the variation of the presentation. There are numerous scales in this regard. Depending on the score given by them, the clinical probability of suffering from this disease can be concluded. Since clinical impression is often nonspecific, because many of the symptoms are common among many patients who do not have this disease, clinical prediction scales are necessary.

Background: 

Sepsis is a disorder that commonly encountered in the emergency department (ED) with high morbidity and mortality worldwide. Conventional investigations of biomarkers for sepsis were limited to the time patients diagnosed with sepsis. However, sepsis is a dynamic illness that could manifest differently from time to time. Previously, researchers either focused on specific biomarkers for the longitudinal change, or comparison of different biomarkers at a single time point. 

 

Methods: 

We conducted a prospective hospital-based cohort study in two EDs in the tertiary hospitals in Northern Taiwan with patients with documented infectious diseases during the initial24 hours between 2012 and 2018. We evaluated the performance of 15 novel biomarkers along with some conventional biomarkers and the symptoms and signs in prognosticating outcome for patients with suspected sepsis in ED. We applied the multiplex platform of Bio-Plex ProTM Assays to evaluate 15 novel biomarkers: angipoietin-2, pentraxin 3, sTREM-1, ICAM-1, VCAM-1, sCD14 and 163, E- and P-selectin, TNF-alpha, INF-gamma, CD64, IL-6, 8, and 10. Besides, we assessed several conventional markers including albumin, lactate, D-dimer, C-reactive protein, procalcitonin, liver function, renal function, electrolytes, and coagulation profile. Time of symptom onset and other symptoms and signs were collected prospectively by dedicated research coordinators. Sepsis-associated mortality was defined by chart review to include cases developed inpatient mortality developed related to the initial infectious insult. Logistic regression and odds ratios were used to evaluate the association between the standardized level of biomarkers and mortality. Trend-tests were performed to evaluate the temporal trend of these biomarkers. 

 

Results: 

A total of 1478 patients were enrolled, among them 882 were male (59.68%), 675 were older than 65 years of age (45.67%), 1155 had SIRS (78.15%), 912 had severe sepsis (or Sepsis 3.0, 61.71%), and 466 had septic shock (31.53%) with a mortality rate of 9.2%. The median day after symptoms onset was 2 (IQR: 1 – 4). We found the trend that an early elevated level of VCAM-1, INF-gamma and CD64 and the late elevated level of lactate, uric acid, RBC count and AST were associated with mortality. We also found a decreased level of albumin, calcium, C3, and protein C, red blood cell, platelet, and eosinophil count were constantly associated with mortality. Furthermore, symptoms of chills and fever were constantly associated with survivorship. The most important biomarkers identified were day-4-5 p-selectin (OR: 3.25, 95% C.I. 1.04-10.2, p=0.043) and albumin (OR: 0.26, 95% C.I. 0.14-0.49, p=<0.001)

 

Conclusion: 

In this prospective hospital-based cohort study, we found that the course of illness could be an important factor while evaluating the associations between some biomarkers and outcome of patients with suspected sepsis. 

The study was supported by the Ministry of Science and Technology and Chang Gung Memorial Hospital in Taiwan Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Background and objectives

Bronchiolitis is the most common reason for infants to be hospitalised following presentation to emergency departments (EDs).  Management is supportive with high-level evidence of no efficacy for salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline. Despite all international guidelines recommending against the use of these therapies, significant practice variation exists, with the use of inappropriate therapy a worldwide problem. Knowledge translation (KT) interventions that are tailored to the factors that influence practice can improve care; however there is little high-level evidence in acute paediatrics. The primary objective was to establish whether tailored, theory informed KT interventions, compared to passive guideline dissemination, reduces the use of salbutamol, glucocorticoids, chest x-rays, antibiotics, and adrenaline, in infants <1 year of age with bronchiolitis.

Methods

Tailored KT interventions were developed, following qualitative interviews using the Theoretical Domains Framework, to target key identified factors influencing bronchiolitis management. We then compared the tailored KT interventions versus passive dissemination in a cluster randomised controlled trial of 26 hospitals in Australia and New Zealand during the 2017 Australasian bronchiolitis season. The primary outcome was compliance with the Australasian Bronchiolitis Guideline during the acute care period (first 24 hours of care) with no use of salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline. Secondary outcomes included compliance in ED, compliance in in-patients, compliance during total hospitalisation, compliance for individual therapies and length of stay. Analysis was by intention-to-treat using Generalised Linear Mixed Models.

 

Results

Baseline data was collected on 8,045 infants from all 26 sites for 3 years prior to the intervention year (2014-16 bronchiolitis seasons). There were no major differences between the intervention and control sites. Data was collected on 3,727 infants for the intervention year (2017). Compliance with the Australasian Bronchiolitis Guideline for the acute care period was 85.1% (95%CI 82.6-89.7%) in the intervention sites and 73.0% (95%CI 65.3-78.8%) in the control sites, risk difference 14.1% (95%CI 6.5-21.7%), p<0.001. Compliance while in ED was 87.2% in the intervention sites and 78.8% in the control sites, risk difference 10.8% (95%CI 4.1-17.4%), p=0.002. Compliance in in-patients was 90.5% in the intervention sites and 83.0% in the control sites, risk difference 8.5% (95%CI 2.7-14.3%), p=0.004. Compliance during total hospitalisation was 82.2% in the intervention sites and 69.9% in the control sites, risk difference 14.4% (95%CI 6.2-22.6%), p<0.001. Median length of stay was 0.5 days in the intervention sites and 0.5 days in the control sites, incident rate ratio 0.9 (95%CI 0.7-1.2), p=0.67.   

 

Conclusions

The use of tailored KT interventions substantially reduces the use of inappropriate therapies in the management of infants with bronchiolitis. As bronchiolitis is the most common reason for infants to be admitted to hospital this study has important implications for future management of bronchiolitis and worldwide for KT for paediatric presentations to EDs. 

The trial is registered in the Australian and New Zealand Clinical Trials Registry (ACTRN12616001567415). Supported by a National Health and Medical Research Council Centre of Research Excellence grant for Paediatric Emergency Medicine (GNT1058560), Australia and the Health Research Council of New Zealand (HRC 13/556).

Backgorund:

Sepsis is a leading cause of hospital mortality world wide. We know that time to treatment reduce morbidity and mortality. We don't know if implementation of a shock alert forcing physicians to select the cause of shock and if sepsis, guiding them to resuscitation goals, will lead to improved time to treatment and mortality. The primary objective was to evaluate time to treatment with antibiotic and IV fluids and the outcome of patients presenting with shock and impression of sepsis, before and after implementation of an electronic ShockAlert.

Design and Method: This is a ambispective before and after study of patients presenting with Septic Shock to an academic tertiary Emergency Department before and after implementation of an electronic Shock Alert; May 16, 2013 through November 13, 2014 and January 15, 2015 through January 14, 2017. Patients were defined as having sepsis when they met Shock Alert criteria (a single episode of either hypotension (systolic blood pressure ≤ 90 mmHg) or Lactate ≥ 4 mmol/L) and had a physician impression of sepsis. In the pre-implementation group, subjects were identified by retrospectively applying Shock Alert criteria to all patients ED patients and by chart review identifying patients with sepsis or septic shock as the cause of shock. Subjects in the post group were identified through the Shock Alert tool (AWARE). Time to antibiotic was calculated in both groups and defined as time from ED arrival to the first antibiotic was ordered. Time to IV fluids was calculated similarly.

Continuous features were summarized with means and standard deviations when approximately normally distributed and with medians and interquartile ranges (IQRs) otherwise; categorical features were summarized with frequency counts and percentages. Features were compared between patient visits before and after implementation of the electronic sepsis notification system using two-sample t, Wilcoxon rank sum, chi-square, and Fisher exact tests based on the type and distribution of the feature under study.

Results: A total of 670 patients were eligible for this cohort study, 270 (40%) from the pre-implementation period and 400 (60%) from the post-implementation period. The mean age at ED arrival was 70 years in the pre-cohort and 68 years in the post-cohort (p 0,23), 58% and 57% were men in the pre- and post- implementation cohort respectively. The median time to first antibiotic was 1.7 (0.8-2.6) hours pre-implementation and 1.2 (0.7-2.3) hours post (p<0,001). In the pre-group, 38% received ≥30 ml/kg fluids within 3 hours from trigger time, this was 46% in the post group (p=0.039). The ICU admission rate was 61% pre-implementation and 73% post implementation (p=0.001). We found an in-hospital mortality in the pre and post group respectively of 15% and 8% (p=0.002)

Conclusions: This study shows a significantly reduced time to antibiotic treatment and order of ≥30 ml/kg IV fluids to patients presenting to the Emergency Department with sepsis or septic shock after implementation of an electronic Shock Alert. We found an increased rate of ICU admission and significantly decreased in-hospital mortality after implementation of the electronic Shock Alert.

No funding IRB approved study

Background

Many patients die from sepsis and multiple organ failure, even though proper management in hemorrhagic shock patients. Early diagnosis of sepsis in hemorrhagic shock patients is important and used in various ways, such as CRP and WBC, procalcitonin (PCT), but they have some problems. Recently, macrophage migration inhibitory factor (MIF) have emerged as predictive factors. Our study aims to explore the significance of MIF as a predictor of sepsis in hemorrhagic shock patients.

Methods

This study was conducted on prospective observational study patients who visited an emergency medical center in a university hospital from March 1, 2018 to December 31, 2018 and were intended for hemorrhagic shock patients aged 15 or older. We measured WBC, CRP, PCT, MIF, TNF-α, Interleukin-6 (IL-6), and lactic acid with serum taken from the patient's blood. The definition of sepsis was defined as being part of SIRS criteria with infections within a week.

Results

180 hemorrhagic shock patients were registered in emergency department, 28 of whom had sepsis within a week. The CRP, WBC, TNF-α, IL-6 did not differ in the comparison between sepsis and non-sepsis patients, while the PCT was somewhat high in sepsis patients (0.24±0.1ng/mL > 0.18±0.07ng/mL), but with had no statistical significance. However, MIF was significantly elevated in sepsis (2633±710pg/mL) to non-sepsis group (1460±680pg/mL). There was no correlation between MIF and lactic acid, which is the diagnostic criteria of shock.

Discussion & Conclusions

It is believed that MIF may be used as a measure of sepsis in hemorrhagic shock patients. However, more research on the occurrence of MIF is thought to be necessary.

This study used in hemorrhagic shock patients (#180) This research was supported Basic Science research program through the National Research FOundation (NRF) funding by the Ministry of Education, Science and Technology (R1804431), and was partially supported a Korea University Grant This study protocol and informed consent documents were reviewed and approved of Korea University Guro Hospital (IRB No. 2018GR0155)

Background&objective: The lifetime risk of heart failure is estimated to be 1 in 5 and is one of the leading causes of hospitalization in the United States in patients aged 65 and older. Sepsis is a leading causes of death in hospitals. Concurrent heart failure and sepsis presents a treatment paradox: Heart failure mangement focuses on managing and avoiding fluid overload whereas fluid administration is a key element in the treatment of septic shock. We studied the difference in fluid administration and mortality between septic patients with and without pre-existing heart failure.

Design and Method: This is a retrospective study of a consecutive cohort of 837 patients who presented to the emergency department (ED) of an American suburban academic medical center between May 2013 and January 2017. All patients presented with either hypotension (≤ 90 mmHg), an elevated lactate (≥ 4 mmol/L) or a combination and had a physician impression of sepsis recorded during the ED course. Patients were divided into two groups based on ICD-9/10 diagnosis of heart failure before ED arrival; there were 306 (37%) with pre-existing heart failure and 531 (63%) without. Additionally, the pre-existing heart failure group was subdivided into HFpEF and HFrEF based on the most recent ECHO before admission; there were 142 (46%) with a reduced ejection fraction <50% and 164 (54%) with a preserved ejection fraction ≥50%. Comparisons of total fluids ordered at 3 and 6 hours, ICU admission, ventilatory support and mortality between patient groups after adjusting for chronic kidney disease were evaluated using multivariable linear and logistic regression models.

Results: Patients with pre-existing heart failure received less fluid at 3 hours (mean 26.3 vs 30.7 ml/kg; p=0.009) and at 6 hours (mean 38.4 vs 45.0 ml/kg; p=0.003) compared to patients without heart failure after adjusting for chronic kidney disease. The adjusted odds ratio for the association of heart failure with ICU admission was 1.57 (95% CI 1.14-2.18; p=0.006), Patients with heart failure were not more likely to need intubation or vasopressors (p=0.35 and 0.22). Those with heart failure did trend toward an increased likelihood to die in-hospital or within 30 days, but these differences were not statistically significant in a univariable setting or after multivariable adjustment in this sample (p=0.10 and 0.14 respectively). However, the adjusted odds ratio for the association of heart failure with 90-day mortality was 1.46 (95% CI 1.03-2.06; p=0.032). There were no statistically significant differences in the outcomes studied between heart failure patients with reduced and preserved ejection fraction.

Conclusion: Patients with pre-existing heart failure who present to the ED receive significantly less fluid than patients without pre-existing heart failure at 3 and 6 hours after ED arrival and are more likely to require ICU admission during hospitalization. 90-day mortality is increased among patients with pre-existing heart failure. Based on the results of the current study, heart failure type does not appear to significantly affect the course of sepsis and septic shock.

IRB approved No funding Informed consent waived

Introduction: Contextualization and reproducibility are features of high fidelity simulation that have allowed it to take an advanced place in the medical curriculum. Teaching by "video-case" is a teaching tool based on placing the learner at the center of his learning. The objective of the study is to compare these two means of learning in the acquisition of skills concerning the management of hypertensive emergency crises.

Material and methods: Randomized prospective study including emergency family medicine residents randomized into 2 groups: simulation group, video-case group for the same educational objective: management of an hypertensive emergency crises. After randomization, the study starts with a pre-test of 10 multiple-choice questions in 10 minutes on the prerequisite knowledge. After the two teaching sessions, students are asked to repeat the same test in multiple choice questions under the same conditions to compare the progress for each student and between the two groups.As a Judgment Criterion we retained the student progression judged by significant increase in average marks between pre-test and post-test.

Results: A total of 38 residents are included whose average age is 27.6 years with a sex ratio of 0.5. The pre-test average was comparable between the two groups: 9.2 / 20 (+/- 1.9) for the simulation group and 9.4 / 20 (+/- 1.7) for the video-case group (p = 0.268). For the post-test, averages increase significantly within each group. It goes from 9.2 / 20 (+/- 1.9) to 13.44 (+/- 1.28) (P <0.001) in the simulation group and from 9.4 / 20 (+/- 1.7) to 11.91 (+/- 1.5) ( P <0.001) in the video-box group. Relative progression is greater for the simulation group (P <0.03).

Conclusion: The superiority of simulation method over video-case teaching is concluded.

 

Background: Gabapentin prescriptions have by 64% between 2012 and 2016, in part due to the off label use for conditions like chronic pain. It was also one of the most commonly reported drug causing overdose deaths in the United States from 2011 through 2016. It has been noted that almost one-fifth of the patients who abuse opioids, also abuse gabapentin. The objective of the study was to describe the epidemiology of gabapentin exposures using a near real-time national poison center (PC) database.

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

Results: There were 122,810 gabapentin human exposures reported to the PCs from 2012 to 2018, with the number of calls increasing from 11,336 to 22,776 during the study period. Polysubstance exposures accounted for 65.2% of gabapentin exposures. Of the total gabapentin calls, the proportion of calls from acute care hospitals and EDs increased from 55.1% to 64.7% during the study period. Multiple substance exposures accounted for 75.4% of the calls from acute care hospitals and EDs. Approximately 21% of the patients reporting gabapentin exposures were admitted to the critical care unit (CCU), while 21.3% patients were treated and released. Residence was the most common site of exposure (94.5%), and 68.2% cases were enroute to the hospital when the PC was notified. Among the patients, 59.1% were females, with the majority of gabapentin exposures occurring between the ages of 40-59 years (33.5%). Suspected suicides (51.6%) was the most commonly reported reason for exposure. The proportion of such cases was higher in reports from acute care hospitals and EDs (71.5%). During the study period, the proportion of suspected suicides increased (46.8% to 54.4%) among gabapentin exposures. Major effects were seen in 5.5% cases and the case fatality rate was 0.4%. Notably, there was an approximately 2-fold increase in the number of deaths during the study period. The most frequently co-occurring substances associated with the cases were benzodiazepines (16.7%) and antipsychotics (10.7%). Tachycardia (16.1%) and hypertension (8.5%) were commonly observed clinical effects. During the study period, the frequency of gabapentin exposures increased by 200.9% (95% CI: 196.4%, 205.5%; p<0.001), and the rate of gabapentin exposures increased by 217.8% (95% CI: 195.8%, 242.2%; p<0.001).

Conclusions:  Gabapentin exposures increased during the study period. Abuse and diversion of gabapentin may be as a result of its low cost and non-schedule status. Gabapentin has also been increasingly associated with suicidal ideation, the most common reason for exposure in our sample. Increasing prescriber awareness and better screening may be key to reduce such overdoses.

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Objectives: Misuse of prescription opioids continues to be a significant public health crisis globally. The number of patients with opioid dependence worldwide was estimated to be 15.5 million in 2010. According to the Centers for Disease Control and Prevention (CDC), there were more than 72,000 overdose deaths in the United States (U.S.), with 49,068 involving an opioid, with 11.4 million misusing prescription pain medicine. The present study sought to evaluate the recent trends in the severe outcomes to opioid exposures reported to the U.S. poison centers (PCs).

Methods: The NPDS was queried for opioid exposures that were reported from 2012 to 2017. Cases with severe outcomes (SO) were defined as exposures that resulted in either a death or major clinical outcomes We descriptively assessed the demographic and clinical characteristics. Calls from acute care hospitals and emergency departments (ACH) were studied. Poisson regression was used to evaluate the trends in the number and rates (per 100,000 human exposures) of opioid exposures resulting in SO. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

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

Conclusions: The number of SS cases handled by the PCs decreased significantly. Moreover, there was a low fatality rate.  Hydrocodone and tramadol were the most common opioid reported for the sample. Personalized evidence-based strategies, population-level interventions, creation of protective environments, and better screening of patients at risk of suicide are some key measure to limit this trend. PCs should play a significant role in the care of this patient population and become involved earlier in the case. 

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Background: Torsade de Pointes (TdP) from drug-induced QT prolongation is rare, but life-threatening.  Corrected QT with a cut-off value has long been widely used to estimate the probability of TdP. However, it is neither sensitive nor specific enough. This study sought to construct a clinical prediction rule using multiple risk factors for drug-induced TdP.

Methods: The study population was drawn from a previous retrospective case-control study. Within the case group, a systematic review from Medline was undertaken from the point of its establishment to 10th December 2015. All subjects were adults exposed to QT-prolonging drugs and had TdP. A total 230 patients were included. The control group consisted of 291 patients from 3 hospitals in Atlanta, Georgia, USA, admitted from 2008 to 2010. They had overdosed on QT-prolonging medications but did not develop TdP later. Univariate and multivariate analyses were done to identify significant risk factors. The coefficient of each significant risk factor was converted to a score. Scores were categorized as low, intermediate, and high probability for TdP. Area under the ROC curve (AUROC) and likelihood ratio were calculated.

Results: Univariate analysis revealed 6 significant factors: age>65 years old, female, underlying heart disease, heart rate <60 beats/minute, QTcB (Bazett’s formula) >490 milliseconds (ms), and exposure to drugs known to cause TdP based on Crediblemeds.org. For the multivariate analysis, only old age, slow heart rate, QTcB >490 ms, and exposure to drugs known to cause TdP were significant. The Hosmer-Lemeshow test was 0.89. A scoring system was invented based on the coefficients of these significant risk factors.  The clinical prediction rule has an AUROC of 0.98 (95%CI: 0.97-0.99). In the low risk group, likelihood ratio for TdP was 0.02 (95%CI: 0.01-0.06), and in the high risk one, the likelihood ratio was 120 (95%CI: 30-479).

Conclusions: This clinical prediction rule using multiple risk factors, including QTcB >490 ms, provided very high performance for predicting TdP in those who were exposed to QT-prolonging drugs. However, this rule still needs to be validated.