Results of a survey on the preanalytical process in the emergency department have been published in the  Clinical Chemistry and Laboratory Medicine journal.

This survey  was supported by the European Society for Emergency Nursing (EUSEN), European Society for Emergency Medicine (EuSEM), and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM).  

The EM-Day taskforce has written a policy statement about minimal standards for safe working conditions in Emergency Medicine. It is published in the European Journal for Emergency Medicine. Share it as much as you can so it will be noticed by our policy makers.

https://journals.lww.com/euro-emergencymed/Fulltext/9900/Policy_statement_on_minimal_standards_for_safe.35.aspx 

TheCase.Report is a collaboration by EUSEM's Geriatric society and European Geriatric Medicine Society (EUGMS).

Podcasts have been released https://www.thecase.report/episodes/2022/10/16/tcr-x-geriem

Also check out great posters https://posters.geriemeurope.eu/ with great educational content. 

Berlin, Germany: Pulse oximetry is an unreliable method for spotting people suffering with carbon monoxide poisoning and it should not be used for this purpose, according to a systematic review and meta-analysis presented today (Tuesday) at the European Emergency Medicine Congress [1].

Carbon monoxide is one of the most common causes of poisoning death in the world [2]. It can be successfully treated with oxygen. However carbon monoxide poisoning can be difficult to diagnose because its symptoms are similar to common infections such as flu.

Researchers say more work is now needed to find a quick and effective method for diagnosing carbon monoxide poisoning.

Carbon monoxide is a colourless, odourless gas that can be produced when fuels burn in a poorly ventilated space, for example in a faulty or poorly maintained boiler or gas cooker. When people are exposed to carbon monoxide, it enters their bloodstream via the lungs. Carbon monoxide attaches to haemoglobin – the molecule that normally transports oxygen around the body and this can result in the body being starved of oxygen.

Carbon monoxide poisoning can be detected with a blood test that measures the proportion of haemoglobin that is bound to carbon monoxide.

The new findings were presented by Dr Mathilde Papin from the emergency department at Nantes University Hospital in France. She said: “If we suspect carbon monoxide poisoning, we want to be able to treat patients quickly with oxygen in the ambulance or in the emergency room, and that means we need a test that can be done immediately onsite. A blood test is reliable, but not practical.”

Pulse oximetry is a quick and easy test where a monitor, usually placed on the fingertip, can measure a patient’s pulse and gauge the proportion of their blood that is loaded with oxygen (called oxygen saturation). It is used to monitor patients with lung conditions such as asthma or chest infections.

A lower level of oxygen saturation might also indicate that a patient has been exposed to carbon dioxide, which is displacing the oxygen in their blood. However, Dr Papin added: “The use of pulse oximetry to check for carbon monoxide poisoning in research and in clinical practice has given mixed results.”

To gain a clearer picture, Dr Papin and her colleagues conducted a systematic review and meta-analysis. They searched for all previous medical trials that compared pulse oximetry with blood tests in patients or healthy volunteers, including adults and children, and found 19 such studies. The researchers were able to combine the results from 11 of the studies, including data on more than 2000 people, to compare the accuracy of the two testing approaches.

This showed that pulse oximetry was able to correctly detect positive cases (the true positive rate or “sensitivity”) 77% of the time. It could correctly identify negative cases (the true negative rate or “specificity”) 83% of the time. Its overall accuracy was 86%.

Dr Papin told the Congress: “At 23%, the false negative rate with pulse oximetry is too high for reliably triaging patients with suspected carbon monoxide poisoning. This method is not accurate enough and should not be used in clinical practice.”

The researchers now plan to evaluate an alternative method for more rapid screening of levels of carbon monoxide in the small blood vessels (capillaries).

Professor Youri Yordanov from the St Antoine Hospital emergency department, APHP Paris, France, is Chair of the EUSEM 2022 abstract committee and was not involved in the research. He says: “After systematically assessing all the available evidence on the topic, this research team suggests that using pulse oximetry as a tool for diagnosing carbon monoxide poisoning is not a reliable method for this purpose. Other screening methods need to be developed and evaluated, and in the meantime, we must rely on a combination of symptoms, evaluating the likelihood of exposure to carbon monoxide and blood tests.”

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[1] Abstract no: OA085, “Accuracy of pulse CO-oximetry to evaluate blood carboxyhemoglobin level: a systematic review and meta-analysis” by Mathilde Papin, in the Toxicology session, 14:40 - 16:05 hrs CEST, Tuesday 18 October.

[2] Estimated incidence of 137 cases per million and 4.6 deaths per million.

Berlin, Germany: In a survey of emergency department staff from across Europe, only around half said their hospital has a policy in place to help staff identify children who are being neglected or abused.

The research, presented at the European Emergency Medicine Congress [1], also shows that hospitals with such a policy are more likely to use strategies that are known to be effective in identifying children who are maltreated, including screening tools and staff training.

The study was presented by Féline Hoedeman, a PhD and medical student at the Erasmus MC Sophia Children’s Hospital in Rotterdam, The Netherlands. She said: “Abuse and neglect have devastating effects on children, families and society, but they can be very difficult to spot. Children who sustain injuries due to abuse are likely to present at an emergency department and previous research shows that staff can play an important part in identifying these children, especially if they have the right training, tools and resources.”

In collaboration with the Dutch Augeo Foundation, the European Society for Emergency Medicine (EUSEM), Research in European Paediatric Emergency Medicine (REPEM) network and the European Society of Emergency Nursing (EuSEN), the researchers from the Erasmus MC Sophia Children’s Hospital conducted a survey of healthcare professionals working in European emergency departments. The responses came from staff at 148 hospitals in 29 countries: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Kosovo, Latvia, Lithuania, Malta, The Netherlands, Norway, Poland, Romania, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom.

Only 51% of respondents said their hospital had a standardised child maltreatment policy. Twenty-four percent said they did not have such a policy. The remaining 25% either did not know or did not say whether they had a policy.

Those who said there was a policy were also more likely to report that their hospital had a child maltreatment screening tool (52% compared to 2% in hospitals without a policy), training on identifying maltreated children (63% compared with 30%), a child abuse team (73% compared with 27%) and a child maltreatment policy officer (51% compared to 20%). However, only 28% with a policy said that their hospital used all four of these strategies.

The researchers caution that the responses came from individual professionals and so are not representative of all hospital staff. 

Ms Hoedeman said: “Our study suggests that there are some hospitals where the right action is being taken to protect children. However, it also suggests that there are far too many hospitals where policy on child abuse and neglect is not in place or staff do not know the policy is there. Where that’s the case, staff are less likely to have the tools and knowledge they need and may be missing opportunities to help vulnerable children.”

The researchers plan to develop a toolkit, consisting of a hospital policy, training and a screening tool, to help identify children being neglected or abused. They have just completed a follow-up survey to investigate any factors that could help or hinder implementation of the toolkit.

Professor Youri Yordanov from the St Antoine Hospital emergency department, APHP Paris, France, is Chair of the EUSEM 2022 abstract committee and was not involved in the research. He says: “We know that having protocols and structured processes in hospitals can reduce medical errors and benefit patients. This study affirms that having a policy can support emergency department staff to spot children who are at risk.

“Although regulations and legal systems differ between European countries, the core components of a child maltreatment hospital policy should always be in place and can be adapted to different hospitals. We are starting to recognise that there is a lot of variability between hospitals when it comes to recognising child abuse and neglect and that’s something we need to urgently address.”

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[1] Abstract no: OA057, “A survey study on hospital policy to improve recognition and management of child maltreatment in Europe” by Féline Hoedeman et al, in the Paediatrics session, 16:35 - 18:00, hrs CEST, Monday 17 October.

Berlin, Germany: The use of digital technology in residential care homes can reduce the number of emergency department attendances by 10% each month, according to new research presented at the European Emergency Medicine Congress today (Wednesday) [1].

Preliminary evidence from a study that modelled the effect of implementing the UK’s National Health Service (NHS) HealthCall digital technology across the North-East of England showed it had the potential to make a significant impact on attendances by residents of care homes in accident and emergency (A&E) departments.

Alex Garner, a PhD student in the Statistics and Epidemiology programme at Lancaster Medical School (Lancaster University, UK), working on the Health Data Research UK funded Learning Care Homes Project, told the congress that HealthCall Digital Care Homes was an app that could be used in care homes to provide staff with easy access to clinical advice.

“Care homes that are registered with HealthCall are provided with devices on which the staff can use the app. Staff are trained on taking observations of residents’ condition, such as body temperature and blood pressure, and uploading these observations to the app. They can also include text about a person’s condition. The observations are sent to a clinician at a central hub who has access to the resident's NHS healthcare record. The clinician can then provide advice for staff on next steps in the resident's care. The advice might be to keep monitoring the resident, or for a healthcare professional to visit, or to take them to an emergency department.”

Mr Garner and his colleagues collated data on 8,702 care home residents in 122 homes from County Durham and Darlington NHS Foundation Trust and linked these with clinical data from HealthCall. Using this information, they created statistical models to predict how rates of A&E attendances changed over time. The models took account of fluctuations caused by the time of year and also the COVID-19 pandemic.

“HealthCall rolled out in care homes gradually throughout the study period of June 2018 to September 2021,” he said. “New homes joined each month, and we can identify when each home started to use the HealthCall system, incorporating this into our statistical models. We assessed whether usage of the app in a care home had a significant impact on expected numbers of A&E attendances. We tested for an immediate change and also for a gradual change over time in emergency attendances.

“Our preliminary models suggest a 10% reduction in the expected monthly emergency department attendances for residents in care homes using HealthCall technology compared to attendance rates before HealthCall was introduced. There is insufficient evidence so far to suggest that the use of HealthCall could result in an additional gradual decrease in emergency attendances for individual residents over time, but we are investigating this further.

“The technology also allows for ongoing monitoring of residents’ health as well as providing more convenient and timely access to clinical advice.”

The researchers continue to develop their modelling and investigate the impact of HealthCall technology on A&E attendances and admission, length of inpatient stays, number of community nurse visits, rates of A&E admissions compared to transfer back to the care homes, rates of A&E arrivals by ambulance, and whether any of these outcomes are affected by how much the care homes use the app. The technology is now being rolled out to a further 300 care homes in the north of England, including in North Cumbria, South Tees, Newcastle Gateshead and Rotherham.

“Our study shows that digital technology could bridge the gap between health care and social care in the UK, provide staff with ready access to clinical expertise and potentially improve the quality of life for care home residents,” said Mr Garner. “Different systems for care home in other countries may mean health care and social care interact in different ways, but the opportunities that technology provides to strengthen these links can be a useful tool for improving care for residents, especially when used to bring clinical expertise into day-to-day decision-making.”

Previous research has suggested that some emergency hospital admissions of care home residents in the UK may have been unnecessary, as well as being detrimental to residents’ well-being.

“Care homes look after some of the most vulnerable members of our society. Ensuring residents receive the correct level of care is of utmost importance. It is hoped that having quick access to this type of advice can lead to reductions in A&E attendances and hospital attendances through providing more targeted care in the home,” he said.

A strength of the study was the use of large amounts of data that are routinely collected within the NHS, including information from hospitals and other specialist medical settings, community care and HealthCall. The linked data were stored in the University of Durham Trusted Research Environment (TRE), which allows the researchers to access the sensitive data remotely while the data remain stored in a secure system.

Professor Youri Yordanov from the St Antoine Hospital emergency department (APHP Paris), France, is Chair of the EUSEM 2022 abstract committee and was not involved in the research. He said: “At a time when overcrowding in emergency departments is becoming a chronic issue, and with an ageing population due to increased life expectancy, initiatives such as this that help to reduce the number of attendances of elderly patients to A&E are welcome and much needed.”

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[1] Abstract no: OA103, “Impact of digital technology in care homes on Emergency Department attendances” by Alex Garner, in the Well-being session, 08.30-10.05 hrs CEST, M1-2-3.