2016: Vienna, Austria

Background

Erythropoietin (EPO), a renal type I cytokine, plays key role in the regulation of erythropoiesis. EPO is also increased at the area of inflammation in addition to erythropoiesis and hypoxia showing an anti-inflammatory mechanism. EPO decreases releasing of proinflammatory factors such as TNFα, IL-6, IL-12/IL-23, reduce production of NO by inhibiting inducible NO synthase (iNOS), shows anti-inflammatory effect by reducing NF-κB dependent immunocytokines production, inhibits reactive oxygen species at neutrophils and changes activity of T cells indirectly by disruption of antigen presentation or affecting signal transmission of antigen presenting cells. EPO shows non-erythropoietic functions such as immunoregulatory effect in autoimmune diseases and tissue protective effect in trauma and ischemia.

Aim

We aimed that whether there is a significant difference between erythropoietin (EPO) levels in patients who were administrated to emergency department with urticaria, angioedema and anaphylaxis or not.

Method

Our study was conducted prospectively in ED during two years. Exclusion criteria: Patients who refused to participate, with previously known anemia, renal failure, liver disease, chronic obstructive pulmonary disease, asthma, any disease affecting bone marrow, and malignancies. Patients were classified as urticaria (just skin lesions), angioedema (skin and/or mucosa signs) and anaphylaxis (according to international anaphylaxis criteria). Blood levels of white blood cell (WBC), neutrophil (NEU), lymphocyte (LEN), eosynophil (EO), basophil (BAS), red blood cell (RBC), haemoglobine, haematocrit (HTC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MHC), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), platelet, platelet distribution width (PDW), creatinine, blood urea nitrogen (BUN) were evaluated. Parameters related to erythropoietin as HTC/EPO, RDW/EPO, WBC/EPO, NEU/EPO, LEN/EPO, RBC/EPO, PLT/EPO, EO/EPO, BAS/EPO were calculated and compared.

Results

156 patients grouped as urticaria (n=62, 41.7%), angioedema (n=56, 35.9%), anaphylaxis (n=38, 24.4%) were included. Of 38 anaphylaxis patients, 65.8% had rash, 50% had itching, 13.2% had facial edema, 21.1% had periorbital edema, 34.2% had perioral edema, 18.4% had tongue edema, 84.2% had shortness of breath. There was no significant difference, in terms of erythropoietin and related parameters among urticaria (6.2±1.7 mlU/ml), angioedema (6.2±1.7 mlU/ml) and anaphylaxis (6.4±1.7 mlU/ml) patients (p=0.799). Erythropoietin levels were significantly higher in patients with uvula edema compared to patients without (6.0±1.7 vs. 6.5±1.6; p=0.027). HTC/EPO and RDW/EPO ratios were lower in patients who had rash than patients who had not (8.0±1.9 vs. 7.1±2.3; p=0.033 and 2.7±0.9 vs. 2.2±0.6, respectively; p=0.013). 

Discussion

EpoR expression in non-hematopoietic tissues is shown in previous studies. A study conducted on cutaneous mast cells of subjects with or without dermatologic diseases showed the presence of soluble EpoR in secretory granules. Other immune cells such as macrophages also can release EPO which activate mast cells in paracrine way to express EpoR. Considering the paracrine effect on mast cells, the tissue level of EPO may be high before blood levels elevated. The relationship of mast cells in different tissues and difference between tissue and blood levels of EPO need further studies.

Conclusion

Urticaria, angioedema, anaphylaxis cannot be differentiated via using levels of erythropoietin. However, uvula edema is correlated with higher erythropoietin levels.  

Background

The critical decision of whether to discharge or admit a patient to the hospital is often made at the hospital’s acute care department. More than half of the patients that present at our acute care department are discharged within 24 h and not admitted to the specialized wards of the hospital. Still, some of these patients are subsequently readmitted or may die. Therefore, improvement of the current methods to prognosticate and assess patient risk must be improved, in order to avoid discharge of high-risk patients.

In this study, we aimed to determine whether the prognostic biomarker: soluble urokinase plasminogen activator receptor (suPAR) was able to predict readmission and mortality in patients who are discharged from the acute care department within 24 h.

Methods

Between 18 November 2013 and 30 September 2015 20,193 patients were admitted to the acute medical department, Copenhagen University Hospital Hvidovre. Follow-up was carried out for 30 days via Danish national registries. suPAR measurements and registry data on diagnoses, vital status etc. were available for 17,262 patients. The Charlson score was calculated and used as a measure of comorbidity burden. Statistical analysis was carried out using Kruskal-Wallis test and multiple Cox regression analysis.

Results

A total of 9623 patients (4459 men and 5164 women) were discharged within 24 h. Median suPAR was 2.3 ng/ml (Interquartile range (IQR) 1.7-3.2) for patients discharged within 24 h, compared with 3.7 ng/ml (IQR 2.5-5.5, P<0.0001) for patients with in-hospital stays longer than 24 h. Median age for patients discharged within 24 h was 52.1 years (IQR 36.0-68.4) and 71.2 years (IQR 57.0-82.0, P<0.0001) for patients with longer admissions.

Among patients who were discharged within 24 h, 174 patients (1.8%) died and 1262 patients (13.1%) were readmitted during 30-day follow-up. In comparison, 685 patients (9.0%) died and 1639 (21.5%) were readmitted among patients with in-hospital stays longer than 24 h.

For patients discharged within 24 h, the median suPAR level among those who survived and were not readmitted during follow-up (n=8230) was 2.2 ng/ml (IQR 1.7-3.1). Patients who were readmitted had a slightly elevated suPAR level of 2.8 ng/ml (IQR 2.0-4.0, P<0.0001), and those who died had a median suPAR of 6.9 ng/ml (IQR 4.3-9.7, P<0.0001).

In multiple Cox regression analyses of log2-transformed suPAR values adjusted for age, sex, Charlson score, and C-reactive protein, the HRs for 30-day mortality and readmission were 2.90 (95% confidence interval (CI) 2.25-3.75) and 1.43 (95% CI 1.33-1.53), respectively, for patients discharged within 24 h. For patients with in-hospital stays longer than 24 h, the HRs were 2.06 (95% CI 1.86-2.28, P 0.0002) for 30-day mortality and 1.21 (95% CI 1.14-1.29, P 0.01) for 30-day readmission.

Conclusion

Patients with short admissions (<24 h) had lower suPAR levels as well as 30-day readmission and mortality rates, however, among these patients, a high suPAR level was associated with an increased risk of readmission and mortality compared with patients with in-hospital stays longer than 24 h.

Background: Risk stratification with systematic triage plays a pivotal role in the emergency setting, ensuring that acutely sick patients are cared for first and observed closest. Current triage algorithms serve as risk stratification tools in many emergency departments (ED) and are all based on a combination of the patients’ vital parameters and primary symptoms. Several retrospective studies have identified biomarkers that contain prognostic information, which goes beyond the current triage utilized, and these studies suggests biomarkers as supplement to triage to improve risk stratification. Identifying patients at high and low risk shortly after admission can guide clinical decision-making towards the patients in need, regarding treatment, observation, and allocation of resources. 

Whether the implementation of a prognostic biomarker in initial risk stratification of acutely admitted patients translates into better management and treatment and actually decreases mortality, morbidity, admissions or readmissions has yet to be shown.

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker with potential use in the EDs, as several studies have found it to be an independent predictor of 30-day mortality and adverse outcomes such as readmission, admission to ICU, and longer length of stay. The suPAR blood level reflects immune activation, and it is strongly associated with presence, prognosis, and severity of a broad variety of acute and chronic diseases, as well as being a predictor of disease development in the general population. Although unspecific, suPAR might be an ideal biomarker for risk stratification of unselected patients. 

Study hypothesis: The main hypothesis is that the introduction, fast measurement, and immediate reporting of the suPAR level to the attending physicians in the EDs will enhance risk stratification and be associated with an absolute risk reduction in all-cause mortality at 10 months after inclusion by 1.5%.  The suPAR level can draw attention towards patients with an unrecognized high risk, leading to improved diagnosis and treatment.

Method: The study is designed as an open cross-over cluster-randomized interventional multicenter trial. suPAR is included in the routine blood work of all eligible patients admitted acutely during the interventional period, measured within 2 hours after admission, and immediately reported to the treating physicians in the ED. Prior to the inclusion period, these physicians are educated in the prognostic capabilities of suPAR.

Results: The inclusion period began January 11^th 2016 and ends June 6^th 2016.  The study aims to include 10.000 patients in both the interventional and control arm. Results regarding the primary outcome are expected to be presented in 2017. 

Conclusion: The present abstract describes the design and rationale of the TRIAGE III trial. If our hypothesis is confirmed, strong considerations should be given towards standardizing prognostic biomarkers as routine blood work in relation to early risk stratification in the ED. The TRIAGE III trial has the potential to investigate the concept: Having prognostic information can change the patients prognosis. This concept is central in triage and several other clinical situations, and the study might therefore have a central impact on future clinical organizing and decision-making.

Background: The demand for emergency department (ED) care and non-elective hospital admissions exhibit “natural” variability and do not vary significantly by day of the week. In contrast, the elective surgical schedule is subject to “artificial” variability and is created, in large part, for the convenience of physicians. Consequently, the majority of patients requiring elective surgical procedures are admitted on Mondays and the procedures are subsequently performed on Tuesdays, Wednesdays and Thursdays. Many of these patients occupy a hospital bed post-operatively. We examined the effect of “smoothing” or balancing the elective surgical schedule over the five weekdays on ED length of stay as a surrogate marker of ED crowding. Previous literature has demonstrated that each additional elective surgical case can prolong the mean length of stay per ED patient because of competition for in-patient beds.

Methods: The Division of Vascular Surgery was asked to each limit the number of elective surgical cases to no more than two per day. Based on previous experience, two cases per day for five days exceeded the number that the vascular surgeons typically performed in a week. Agreement with this new paradigm was accomplished by assuring surgeons that they would be able to perform all elective cases in timely fashion and that no case would be turned away. A similar plan was developed for the Department of Thoracic Surgery. After implementation, the need for in-patient beds for elective surgical cases was measured for both services. The number of direct nursing hours on the floors that received these post-operative patients was measured since the demand for nursing staffing was expected to become more predictable. Finally, the time from ED decision to admit to actual departure to the floor, and, total length of stay for admitted ED patients were measured.

Results: The interventions were successful in limiting the number of elective vascular and thoracic surgical cases requiring in-patient beds to the maximum of two cases per day per service. The number of direct nursing hours decreased by over 6% from 8.66 hours per patient day to 8.16 after “smoothing” of the surgical schedule. This resulting in a savings of several hundreds of thousands of dollars because of more predictable nursing scheduling and fewer overtime payments. The time from ED presentation to decision to admit did not change; but, the time from decision to admit to departure for the floor for admitted patients decreased by a mean of 30 minutes (19%) per patient from 162 to 132 minutes. As a result, the total ED length of stay for admitted patients decreased by a mean of 30 minutes.

Conclusion: “Smoothing” the elective surgical schedule can result in lowering costs for overtime pay on the nursing floors that receive these patient postoperatively. Moreover, by reducing “artificial” variability in surgical scheduling we were able to reduce the total length of stay for patients admitted from the ED by a mean of 30 minutes.

Background: The percentage of patients who leave without being seen (LWBS) by a physician is commonly used as a surrogate marker of ED crowding. In December 2012, a new ED opened at Baystate Medical Center in Springfield, Massachusetts. The new ED had 94 licensed beds, four separate Pods and three times the area (72,000 sq. ft.) of the old facility. The demand for ED care grew quickly from a baseline of 265 patients “seen” per day (96,725 per year). The percentage of patients who LWBS quickly became a priority because of a very high daily rate of 8.2% the first month. Nursing leadership on duty was responsible for managing patient flow, but was loosely organized and determined on an ad hoc daily basis.

 Methods: With the goals of improving efficiency, reducing the percentage of patients who LWBS and increasing the number of patients “seen” per day, nursing leadership roles were assigned to selected individuals with demonstrated management skills. Physician staffing was not added. The Charge Nurse was responsible for coordinating care throughout the ED and was responsible for all four Pods. This individual managed current resources and requested additional personnel and equipment when necessary. The Charge Nurse also coordinated the transfer of admitted patients to appropriate in-patient settings and initiated a call for assistance from in-patient services when the boarding of these patients exceeded certain benchmarks. The Flow Coordinator accepted transfers from other facilities and notification of patient arrivals from primary care and specialist physicians. Reports from Emergency Medical Services regarding in-coming traffic were also accepted by the Flow Coordinator. The Pod Lead Nurse assumed the coordination of care within each Pod for every shift. “Direct bedding” of new patients into open ED bays was the became the standard while bypassing the Waiting Room altogether after triage. Measures were calculated over a 3-year period as the mean per week of daily outcomes. The number of patients actually “seen” was approximately normally distributed; therefore, simple linear regression was used for analysis. Total walkouts as a percentage of total volume was analyzed using fractional logistic regression, since the dependent variable was a proportion ranging between 0 and 1.  All analyses were conducted in Stata (version 14.0, StataCorp, Colleg Station, TX).  A critical test level of 5% was considered statistically significant.

 Results: The percentage of patients who LWBS declined steadily over time with a negative trend line reaching 4.5% in December 2015. This was a 45% decrease in three years. The number of patients “seen” rose steadily with a positive trend line to a mean of 316 per day (115,340 per year) in the same timeframe. This represented a 19% increase despite no increase in physicians staffing. The regression lines for both measures were significant at P< 0.001.

 Conclusion: Measures of ED efficiency include the percentage of patients who LWBS and the number of patients “seen” on a daily basis. These outcomes can be improved significantly with a dedicated nursing management structure that is clearly focused on efficiency without adding physician staffing.

Background:

The management in acute coronary syndrome (ACS) is influenced by risk assessment. The Global Registry of Acute Coronary Events (GRACE) and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE) scores are among the most frequently used risk assessment tools. A recently published study on 1,587 patients suggested a clear superiority of the GRACE vs. the CRUSADE score to predict in-hospital mortality and major bleeding. These results were noted controversially in the scientific community.  

Objectives:

We aimed to assess the performance of the GRACE and CRUSADE risk scores to predict in-hospital mortality and major bleeding in a contemporary ACS population at a high-volume centre.

Methods:

All patients treated for ACS from January 1, 2006 to December 31, 2015 at our tertiary care centre were prospectively included in our registry. Demographic and clinical characteristics as well as details on diagnostic findings and therapy were collected according to the Cardiology Audit and Registration Data Standards (CARDS) of the European Society of Cardiology. GRACE and CRUSADE risk scores were calculated. The discrimination capacity of both scores for in-hospital mortality and major bleeding were compared using receiver operating characteristic curves and the method suggested by DeLong et al.

Results:

In total 4,087 patients (874 (21.4%) female; age 62±14 years) were included, 2218 (54.3%) were diagnosed with ST-elevation myocardial infarction (STEMI), 2973 (72.7%) underwent acute percoutaneous coronary intervention (PCI), 92 (2.3%) received thrombolytic therapy, 113 (2.8%) died, and major bleeding occurred in 65 (1.6%).  Based on GRACE risk categories 1,031 patients (25.2%) had low risk, 1,401 patients (34.3%) had intermediate risk, and 1,655 patients (40.5%) had high risk. Risk based on CRUSADE categories was very low/low in 1,505 patients (36.8%), moderate in 924 patients (22.6%), and high/very high risk in 1,658 patients (40.6%). Discrimination capacity for in-hospital mortality of the GRACE score was superior to the CRUSADE score (area under the curve (AUC) 0.91 (95% CI 0.89 - 0.93) vs. 0.83 (95% CI 0.80-0.86); p<0.05). Performance for major bleeding was poor for both scores (AUC 0.71 (0.65-0.76) for GRACE vs. 0.61 (0.55-0.68) for CRUSADE; ns).

Conclusion:

Our findings support a superiority of the GRACE over the CRUSADE score to predict in-hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores to predict it was poor, however there was a trend towards superiority of the GRACE score for this outcome, too.

Introduction

Chest pain is a frequent complaint at the emergency department (ED). It is often difficult to differentiate between an acute coronary syndrome (ACS) and other causes of chest pain. The HEART score is a validated risk score for all patients with chest pain at the ED.

Troponin is one of the key elements of the HEART score. Currently other biomarkers are known to rise early in case of an ACS, such as copeptin and fatty acid binding protein (FABP). We investigated if the accuracy of the HEART score increases by adding copeptin and FABP to the HEART score.

Study design

In 586 patients with chest pain we collected all elements of the HEART score plus copeptin and FABP on arrival at the ED.

We compared the discriminative performances (c-statistic) of the original HEART score vs the HEART score plus copeptin or FABP for the occurrence of Major Adverse Cardiac Events (MACE).

Results

In total 164 patients (28.96 %) reached at least one MACE within six weeks (140 AMI, 88 PCI, 15 CABG, one death). The event rate in patients with a HEART score of zero to three was 0.6%. The c-statistics for MACE were: HEART 0.877, HEART+copeptin 0.877 (p=0.868), HEART+FABP 0.886 (p=0.032).

Conclusions

In this study the addition of copeptin does not improve the HEART score. The addition of FABP slightly improves the discriminating performance of the HEART score in chest pain patients. Adding FABP to the HEART score could improve the rule out of ACS at the ED.

Introduction:

Hemorrhagic complications were associated with short-term mortality in patients with acute coronary syndrome without ST elevation (NSTEMI). The CRUSADE score (Circulation 2009) was used to assess the short-term mortality. But its predictive value for the midterm mortality has been poorly studied.

Objective: We propose to determine the predictive value of the 6 month mortality CRUSADE score for NSTEMI patients seen in the emergency department (ED).

Materials and methods:

A prospective observational study was conducted over two years. Patients with NSTEMI diagnosis was made. Anamnestic, clinical, electrocardiographic, biological and therapeutic criteria were collected. The CRUSADE score was calculated. The prognosis was based on the 6-month mortality. Multivariate analysis by multiple logistic regression was performed.

Results:

Three hundred and ninety patients were included. Mean age 61 + -11 years. Sex ratio to 1.34. Comorbidities N (%): HTA 235 (60), Diabetes 208 (53), dyslipidemia 112 (29), tobacco 101 (26), Coronary Artery Disease 112 (31). Overall mortality at 6 months was 5%. The mean CRUSADE score was higher in the non survivors patients comparing to the survivors: 45± 11 vs 27 ±11 respectively, P <0.001.  The CRUSADE score was predictive of 6 months mortality with a cut-off at 45 with an area under the curve at 0.82, 95% CI [0.74 to 0.90]. Sensitivity = 53%, specificity = 86%, Liklehood ratio (LR) += 3.78, LR- = 0.54.

Conclusion:

Hemorrhagic complications have a major impact on the short and midterm mortality prognosis of NSTEMI patients. Including the CRUSADE score in the management and risk stratification of NSTEMI patients could reduce the midterm mortality.

Introduction:

Dyspnea is a common pattern to seek care in the emergency department (ED). Distinguish cardiac or respiratory origin is a diagnostic challenge for the emergency physicians especially with patients with several comorbidities and intricate clinical presentation.

NT-proBNP is a specific marker of acute heart failure, however, its usefulness in the diagnostic approach of acute dyspnea remains controversial which may  lead us to resort to a echocardigraphy.

Material and methods

Descriptive prospective observational study. Were included all patients who presented to the ED with acute dyspnea and whose etiology remains unclear. Patients with renal impairment have not been included (false positives of NT-pro BNP).

The diagnosis of heart failure was excluded if the NT-proBNP rate was inferior than 300 pg per ml, made if the NT-proBNP was superior than 1800 pg per ml and doubtful if the NT-proBNP rate was between 300 and 1800pg per ml. the rate of NT-pro BNP was adjusted to the patient's age by the standards of the laboratory.

Results:

During one year, 126 patients were included. The mean age was 62 ± 20 years. The sex ratio was 2.33.

The dosage of NT proBNP has laid the diagnosis of acute heart failure in 70% of cases, revealed the respiratory origin of dyspnea in 18% of cases (negative NT-proBNP). In 12% of the remaining cases, we used the transthoracic echocardiography to seek the etiological diagnosis of acute dyspnea.

Conclusion:

The dosage of NT-proBNP has laid the etiological diagnosis of dyspnea in 88% of cases. Through this study we find that the determination of NT-proBNP for any acute dyspnea of uncertain etiology may be useful. The recourse to echocardiography occurred only in 12% of cases

Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) require frequent hospitalization, may necessitate mechanical ventilation (MV) and are associated with a remarkable in-hospital mortality. The BAP-65 score is based on information easily available (elevated blood urea nitrogen [BUN], altered mental status, pulse > 109 beats/min, age > 65 years), and may serve clinicians as a simple risk-stratification tool. We aimed to describe the characteristics of patients attending EDs for an AECOPD, the management of events and the final outcome. We further validated the BAP-65 ability to predict in-hospital death or the need for mechanical ventilation (MV) in a large cohort of AECOPD patients admitted to the ED.

Methods We report the preliminary results of a retrospective analysis of data from 13 Italian EDs in a 12-month period (January-December 2014). Patients aged ≥ 40 years presenting to the ED with either a principal diagnosis of AECOPD or acute respiratory failure with a secondary diagnosis of AECOPD were included in the study. Information on patient demographics, clinical characteristics, including chronic COPD-related treatment, comorbidity burden according to the Charlson Comorbidity Index (CCI), presenting symptoms, BUN level, and ED management was collected. Disposition following ED admission was retrieved. In-hospital mortality or the need for MV served as composite primary outcome. Association between a BAP-65 and the occurrence of composite outcome was investigated through univariate and multivariate logistic regression. We assessed the discrimination of BAP-65 via the area under the receiver operating characteristic curve (AUROC) and the prognostic performance of a BAP-65 score ≥ 4 for the primary outcome.

Results A total of 2098 patients were included in the study; 789 (37.6%) were female, mean age was 74±15 years. Comorbidity burden was low (CCI 0) in 623 (29.7%) cases, moderate (CCI 1-2) in 909 (43.3%), and severe (CCI ≥3) in 566 (26.9%) patients. Almost half cases (n = 1100, 52.7%) required the intervention of the emergency ambulance services. Following the ED visit, 621 cases (29.6%) were sent home; 153 cases (7.3%) received a short-term observation; 1172 (55.9%) were admitted to hospital wards. In-hospital death occurred in 74 patients (3.5%), MV was deemed necessary in 27 (1.3%) cases. Five centres (680 patients) were not able to provide data on BUN and were excluded from the validation analysis. A total of 273 (19.2%) patients had a BAP-65 score ≥ 4. The multivariable analysis showed a significant association between the BAP-65 score and the primary outcome (OR 1.65, 95% CI 1.08-2.53). The AUROC for BAP-65 was 0.67 (95 % CI 0.60-0.75). The sensitivity of BAP-65 score ≥ 4 to predict the composite outcome was 92.5% (95% CI 91.1-93.8), the specificity was 21.6% (95% CI 19.5-23.8)., the positive predictive value was 4.4% (95% CI 3.3-5.4), and the negative predictive value was 98.7 (95% CI 98.1-99.3).

Conclusion: We confirmed BAP-65 score to have high sensitivity and negative predictive value for short-term mortality or use of MV in patients with AECOPD. Our findings suggest that it can be safely used as triage instrument at ED to identify low risk patients.

Background

The original Manchester Acute Coronary Syndromes decision aid (MACS) is a computer-based model that ‘rules in’ and ‘out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as T-MACS, cutting down the biomarkers to just hs-cTnT. Our primary objective was therefore to return to the derivation of the original MACS model but using hs-cTnT as the only biomarker (T-MACS), and then to evaluate the model in three separate external cohort studies. A secondary objective was to compare the predictive characteristics of TMACS to MACS and to the alternative ‘LoD strategy’, by which ACS is excluded in patients with a hs-cTnT concentration below the limit of detection (LoD) of the assay and no ECG ischaemia.

Methods

We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the Emergency Department (ED) with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularization within 30 days. AMI was adjudicated based on reference standard troponin testing (12h after symptom onset or 6h after arrival) with reference to the third universal definition of myocardial infarction. T-MACS was built by logistic regression in one cohort (derivation set) and validated in three external cohorts (validation set).

Results

In the derivation set (n=703), T-MACS could ‘rule out’ 37.7% patients with 99.3% (95% CI 97.3– 99.9%) negative predictive value (NPV) and 98.7% (95.3–99.8%) sensitivity for ACS. In the validation set (n=1,459), T-MACS could ‘rule out’ 40.4% (n=590) patients with 99.3% (98.3–99.8%) NPV and 98.1% (95.2–99.5%) sensitivity. T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs. MACS 0.90 on validation).

In the validation set, original MACS had 100.0% sensitivity, which was not significantly different to T-MACS (absolute difference 1.6%, 95% CI -0.7 to 1.6%, p=0.25) but T-MACS had greater specificity (absolute difference 25.9%, 95% CI 35.3 - 25.9%, p<0.0001) meaning that T-MACS would avoid more hospital admissions. T-MACS had identical sensitivity to the 'LoD strategy' (absolute difference 0.0%, 95% CI -2.2 to 2.2%, p=1.00) but T-MACS had greater specificity (absolute difference 9.8%, 95% CI 6.7 to 12.7%, p<0.0001). Thus, T-MACS would have 'ruled out' ACS in 40.4% patients (n=590) compared to 32.1% (n=468) for the LoD strategy. 

Conclusions

T-MACS could ‘rule out’ ACS in 40% of patients while ‘ruling in’ 5% at highest risk using a single hscTnT measurement on arrival. It has similar sensitivity to the original MACS decision aid and the LoD strategy but greater specificity than both. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources. 

Background

Observational research, including two external validation studies, shows that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes following a single blood test in the Emergency Department (ED). MACS is a computer model that uses a combination of clinical features and two biomarkers (high sensitivity cardiac troponin T and heart-type fatty acid binding protein) to estimate the probability that a patient has an acute coronary syndrome (ACS) and stratify patients into four groups. Patients in the 'very low risk' group could be immediately discharged from hospital in the appropriate clinical circumstances. 

We aimed to evaluate the impact of using the MACS rule in practice. Anticipating a modest effect size that would require a large trial, our objectives were two-fold: (a) to evaluate the feasibility of running a multi-centre randomised controlled trial (RCT) to compare use of the MACS rule to standard practice; and (b) to assess, in patients presenting to the ED with possible acute coronary syndromes, whether use of the MACS rule can increase the proportion of patients safely discharged within 4 hours, compared with contemporary clinical pathways.

Methods

In a pragmatic pilot RCT, consenting patients presenting to two EDs with suspected cardiac chest pain were randomised, stratified by trial centre and MACS risk group in a 1:1 ratio, to receive care guided by the MACS decision rule (intervention group) or standard care according to contemporary guidelines (controls). The primary efficacy outcome was successful discharge from the ED, defined as a decision to discharge within 4h of arrival providing that the patient did not have a missed AMI or develop a major adverse cardiac event (MACE: death, acute myocardial infarction or coronary revascularization) within 30 days. Feasibility outcomes included recruitment and attrition rates, patient satisfaction and acceptability of the MACS decision rule to clinicians.

Results

In total 138 patients were included across 22 weeks, of whom 131 (95%) were randomised (66 in the intervention group and 65 controls). All 131 patients completed 30-day follow up and were included in the final analysis. Seventeen (26%) patients in the intervention group were successfully discharged within 4h compared to 5 (8%) controls (odds ratio 5.5, 95% CI 1.7-17.1, p=0.004). No patients in either group who were discharged within 4h developed MACE. There were no significant differences in patient satisfaction between groups. Clinicians gave a median acceptability score of 5.1/6 indicating high overall acceptability.

Conclusions

In this pilot trial, the MACS rule led to a significant reduction in safe discharges from the ED when used in practice. We have demonstrated the feasibility of a larger trial, which would provide greater statistical power for safety outcomes.

Background: The presence of ST- segment depression (STD) on the admission electrocardiogram (ECG) has been well recognized to be a powerful adverse prognosticator [1].Several clinical trial investigations have further suggested that more extensive STD on admission predicts a greater risk of adverse cardiovascular events [2].

Purpose:The aim of this study was to examine the relationship between the magnitude of STD and adverse events: angina recurrence, myocardial infarction (MI) and death at 30 days.

Methods: A prospective observational study conducted in the emergency department (ED). We enrolled patients aged more than 18 years, presenting to the hospital alive with presumptive diagnosis of ACS and STD on the admission ECG.STD was considered to be present if ≥ 1leads exhibited STD ≥ 0, 05 mV. Three groups were defined according to quantitative ST depression : GP1 < 1 mm, GP2 = 1 - 2 mm , GP3 ≥ 2 mm. Patients with incomplete ECG, left bundle branch block, right bundle branch block, ventricular pacemakers were excluded from the analysis.

Results: Eighty one patients were included, mean age= 61± 11 years, 60%were male. Patients history (%): Smoker (47), hypertension (49), diabetes mellitus (59), hyperlipidemia(10), previous MI(35), heart failure (8%), Previous coronary intervention (18), previous coronary bypass surgery (6). The troponin I was positive in 52 patients. Among patients exhibiting STD on admission we individualized: GP1 (N=37), GP2 (N=33), GP3 (N=11).The magnitude of STD has a significant interaction for all outcomes (P-values for interaction): angina recurrence (0,012), MI (0,002), 30 days mortality (0,003).

Conclusion: Although the presence of STD has been incorporated as an independent dichotomous prognosticator into several trials, the magnitude of STD confers adverse prognosis in patients with NSTEMI-ACS and should be employed to assist medical decision making.

References:

[1] Kaul et al. J Am Coll Cardiol 2001; 38:64-71.

[2] Raymond Tet al. Eur Heart J 2010; 31:958-966

Introduction :

Thrombolytic therapy of acute coronary syndromes with ST segment elevation (STEMI) helped ahieve better outcome especially in hospitals without cath-lab department .

Objetive :

 The purpose of this study was to identify patient characteristics that are a priori predictors of early infarct related artery patency following thrombolytic therapy in patients presenting to the emergency department (ED) with STEMI.

Materiel and method:

Prospective study over a period of 5 years. Were included all the patients admitted to the emergency department with STEMI within less than 12 hours, which were thrombolysed and for whom the results of coronary angiography was collected. Anamnestic, clinical features, treatment and outcome characteristic were collected. The success of lysis was defined by a TIMI III coronary flow.

Results:

During a period of 5 years, 193 patients were included, mean age  58 +/- 11 years, the sex ratio was 6.4. Comorbidities: N (%) : history of smoking 153 (79), Diabetes 63 (32), hypertension 60 (31), dyslipidemia 23 (12%), coronaropathy  8 (4%). The mean time of ED visit was 179 +/- 158 min, with a mean first-time medical thrombolysis contact 32 min +/- 22, and a mean hospital stay of 231 minutes (+/- 325).

In univariate analysis, time of visit to the ED, SBP, history of smoking, diabetes and inferior infraction were identified as predictive factors of success.

In multivariate analysis, only the inferior infraction was identified as predictor of thrombolysis success with OR 1.4, 95% CI [1.04 to 1.89], p = 0.02.

Conclusion :

STEMI in the lower territory have better outcomes after thrombolysis in the ED.

Introduction: The prognosis for patients with an acute coronary syndrome with ST segment elevation (STEMI) is determined by the reperfusion time period. The presence of an intermediary, such as a general practitioner (GP) or cardiologist before the call to the prehospital Emergency Medical Services could help extend these time periods.

Goal: To evaluate patient handling times and the rate of reperfusion decisions by origin of the call to theprehospital Emergency Medical Services.

Methods: Data was retrieved from a regional register of 8 prehospital Emergency Medical Services and 39 medical intensive care units (MICU). Inclusion criteria: patients with a STEMI of less than 24 hours. Exclusion criteria: secondary transfer. Judgement criteria: period between pain and patient handling by MICU and the rate of reperfusion decisions.

Results: 9,858 patients with STEMI were included from 2009 to 2014. The prehospital Emergency Medical Services were called in 6,457 (65%) of the cases by the patient, relative or friend, in 1,209 (12%) of the cases by a GP/cardiologist, in 1,810 (18%) of the cases by firefighters and in 382 (4%) of the cases by other callers. Consistent breakdown over the period was studied. The average period between pain and patient handling was significantly prolonged if the call was from a GP/cardiologist (versus a call by the patient or firefighters) (181 [79-437] minutes versus 50 [20-130] minutes; p <0.0001). By comparison, people using a medical intermediary before calling the prehospital Emergency Medical Services were significantly older (64.2 [53.8 to 76.5] against 60.2 [51.8 to 72.2]), more likely to be women (29.2% against 20.4%), were less typical syndrome (83.7% against 88.5%), had less medical history (90.3% against 92.3%) and had fewer unblocking decisions (89.2% against 95.9%). The main prognosis was not significantly different (3.9% against 4.5%; p = 0.4).

Conclusion: The delay before patient handling was significantly extended if there was an intermediary, GP or cardiologist. These patients, who were older and more often women, with less medical history and more unusual pain, encountered lower rates of reperfusion decisions.

Background

In most cases in which venous thromboembolism (VTE) is developed in the outpatient setting, the Emergency Departments (EDs) is where the disease is actually diagnosed. Surprisingly, however, few studies have analyzed the characteristics of patients with VTE and the disease itself from the perspective of the ED.  This is relevant for several reasons. Firstly, little is known about the epidemiology of VTE in the ED and the risk factors most frequently presented by patients diagnosed with an episode of VTE in the ED. Secondly, few studies have evaluated the most adequate management of patients with VTE by emergency physicians or whether this managment is carried out according to the recommendations of the clinical practice guidelines (CPG), and if this has any repercussion on the final outcome of the patient. Lastly, little is known about the treatment performed in the ED and how this may influence the outcome of the patient.

Aim. The aim of this study was to determine the clinical presentation of VTE and the main risk factors involved in patients diagnosed in Spanish EDs as well as evaluate the management of these patients and adherence to clinical practice guidelines by emergency physicians.

Methods. We performed a prospective cohort study in 53 Spanish EDs, consecutively including patients diagnosed with VTE in the ED. The following data were evaluated: demographic, comorbidities, risk factors for the development of VTE, index event, hemorrhagic risk factors, prognostic factors [pulmonary embolism (PE)] and in-hospital mortality. To evaluate health care quality we determined the percentage of patients registered with clinical probability of PE, requests for D-dimer concentrations according to clinical probability, administration of treatment prior to confirmation of diagnosis based on clinical probability and records of risk of bleeding and prognosis of the patients with VTE. 

Results. Of 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (impact 1.6/1000 visits). Of these, 801 patients were included in the analysis, 49.8% of whom had PE with or without deep venous trhrombosis (DVT).  The most frequent risk factors for VTE were: age (≥70 years), obesity, new immobility, previous VTE and active cancer. In the ED medical reports a scale of clinical probability, the prognosis or the risk of bleeding were only described in 7.6%, 7.5% and 1%, respectively of the cases. Of the patients with PE and high clinical probability, D-dimer was determined in 87.2%, and treatment was initiated prior to confirmation in 35.9%. Regarding risk, 31.3% of the patients with PE presented low risk, 59.1% intermediate-low risk, 6% intermediate-high risk and 3.5% high risk. Of the patients with PE, 98.7% were hospitalized while 50.2% of the VTE (without PE) were admitted. The in-hospital mortality of the patients with PE was 3.8%. 

Conclusion. VTE has an appreciable impact on Spanish EDs. Risk profile for the VTE development  in patients diagnosed in ED being similar to previous studies. Adherence to CPG recommendations needs to significantly improve.

INTRODUCTION

Low molecular weight heparin (LMWH) are commonly prescribed in the emergency department (ED). Not prescribing LMWH for patients with lower limb immobilization (LLI) and at risk for venous thromboembolic events (VTE) can be life-threatening. The incidence of VTE in patients with LLI is estimated between 5 - 39%. The known risk factors for VTE are easily misinterpreted we noticed in our departement. 

METHODS

Participants were asked about their prescribing behavior: the influence of risk factors for VTE, the level of evidence and the need for dose reduction in patients with renal failure.

Ethical committee was obtained and a online questionnaire was created.

RESULTS

75 questionnaires were filled out by physicians, both attendings (65,3%) and residents (32%), working at EDs.

89% of the respondents does not differentiate immobilization of grade III distortions from fractures when prescribing LMWH and 14,9% indicates being influenced by the type of immobilization (splint versus circular cast).

Withholding treatment in patients with known risk factors, other than the immobilization itself, was seen for known risk factors: hormonal therapy (28%), history (24%) and pregnancy (22.6%). Of the respondents 88% recognized that BMI is a risk factor.

56% wrongly indicated being influenced by the patient’s gender in their decision and 4% indicated using the age of 60 or higher as the cut-off for prescribing LMWH.

Renal insufficiency was not taken into account in 39.1% of the responders.

CONCLUSION

It is important to only initiate VTE-prophylaxis in patients where benefits outweigh the possible risks.

Based on the results of our multi-center survey, we can conclude that a lot of physicians aren’t familiar with the correct use of LMWH in the ED. It seems that the role of gender and age is not well known. More surprisingly, more than half of the respondents does not consider LLI itself as risk factor. In contrast, about one fourth of the physicians would not prescribe LMWH even though the patient has a proven risk factor for VTE.

Dose reduction is an important issue in patients with severe renal insufficiency and is apparently easily forgotten.

Even though there is extensive research available about the risk factors for development of VTE, a lot of physicians seem to be having difficulties identifying patients at increased risk. In addition, most research available about the subject is not applicable on the population encountered in the ED. 

The decision pathway is not difficult so flowcharts could easily be created to limit the possibility of errors in interpretation of the risk factors.

Further research is planned based on the results of this research, an international multi-center study is planned to follow this national enquiry.

Background: Half of cardiac arrests (CA) complicating acute coronary syndromes with ST segment elevation (STEMI) occurred during the first two hours. During this initial phase, STEMI were supported in emergency department in the absence of direct orientation to the interventional cardiology structures. Prevalence, risk factors and prognosis of CA complicating STEMI admitted to the emergency department were not well assessed.   

Aim of study:  To study the risk factors and prognosis of cardiac arrest occurring during the initial management of STEMI in the emergency department.

Methods: Prospective observational study extended over a period of 81 months (January 2009-September 2015) in the emergency department of regional hospital in Ben Arous. Inclusion of patients admitted for STEMI lasting for less than 24 hours. The demographic, clinical, electrocardiographic and therapeutic data were collected. Analysis of patients group complicated of CA in emergency department. Identification of factors related to the occurrence of CA using a logistic regression model.

Results: Inclusion of 694 STEMI with a mean age of 60 ± 12 years and a sex ratio of 5. The cardiovascular risk factors were dominated by active smoking (71%) followed by hypertension (35%) and diabetes (32%). The median time of consultation was 150 min (5 min to 24 h). Fibrinolysis was administered in 72% of patients with a success rate of 59%.the most dreaded complications related to the SCA were the cardiogenic shock (10%) and  the cardiac arrest (9%). Patients who experienced CA (n=62) had a mean age of 60 ± 12 years and a male predominance with a sex ratio of 6. Active smoking was the most common cardiovascular risk factor (73%). The median time of consultation was 120 min (30 min and 16 h). Analysis of the initial rhythm of CA objectified ventricular fibrillation (72%), asystole (18%) and ventricular tachycardia (10%). The STEMI was in the anterior territory in 70% of patients and in the lower area in 32% of patients. The treatment in emergency includes (n): External Defibrillation (55), intubation (28), catecholamines (22), anti-arrhythmic (16). Multivariate analysis identified three independent factors related to the occurrence of CA: cardiogenic shock (OR = 2.44 95% CI 1,31- 44,54), reaching the anterior territory (OR = 1 97 95% CI 1.12 to 3.43) and pulsed oxygen saturation less than 90% (OR = 1.05 95% CI 1.02 to 1.09). The mortality of CA in the emergency department was 29%.

Conclusion: Identifying and improving care of risk factors can prevent the occurrence of CA, reduce mortality and improve the short-term prognosis of STEMI.

Aims: This study aimed to evaluate the effects of esmolol treatment for patients with refractory ventricular fibrillation (RVF) and out-of-hospital cardiac arrest (OHCA).

Methods: This single-centre retrospective pre-post study evaluated patients who were treated between January 2012 and December 2015. Some patients had received esmolol (loading dose: 500 µg/kg, infusion: 0–100 µg/kg/min) for RVF (≥3 defibrillation attempts), after obtaining consent from the patient’s guardian.

Results: Twenty-five patients did not receive esmolol (the control group), and 16 patients received esmolol. Sustained return of spontaneous circulation (ROSC) was significantly more common in the esmolol group, compared to the control group (56% vs. 16%, p = 0.007). Survival and good neurological outcomes at 30 days and at 3 months were >2-fold better in the esmolol group, compared to the control group, although these increases were not statistically significant. A multiple logistic regression model revealed that esmolol treatment provided an odds ratio of 9.24 for sustained ROSC (95% confidence interval: 1.64–52.11, p = 0.012).

Conclusions: Among patients with RVF and OHCA, treatment with esmolol was associated with higher rates of sustained ROSC and survival, and patients who received esmolol exhibited an odds ratio of 9.24 for sustained ROSC. Therefore, we suggest considering esmolol for patients with RVF and OHCA after administering standard therapy.

Introduction: Out-of-hospital cardiac arrest (OHCA) in children is a situation that faced by the whole pre-hospital emergency team. The aim of this study was to describe pediatric OHCA heart rhythms recorded by semi-automated external defibrillators (AED) used by on-scene First Aid professionals.

Material and methods: This was a prospective observational study of an urban area with high population density. It included children from 0 to 18 years in OHCA who received an AED.  When used, pediatric electrodes delivered 30 joules of energy.  The collected variables showed a relation to the epidemiological data in accordance with Utstein's recommendations, as well as the electrocardiographic data from the AEDs.

Vincent Thomas, Sabine Lemoine, Daniel Jost, Vincent Lanoë, Marilyn Franchin, Benoit Frattini, Michel Bignand, Jean-Pierre Tourtier 

Results: Over a period of 4 years, 229 children were included and 191 AED plots were analyzed.  The median [Inter Quartile Range] age was 6 [5-16] years, with 129 boys (56%). Twenty-eight children (12%) had a shockable rhythm on the First Aid workers' arrival and were multi-shocked in 39% of cases. The fraction of time devoted to external chest compressions over the total time of care was 60%. The AED reported shock in 3 children and administered an excessive shock in 1 case. The rate of successful defibrillation was 95.4%.

Conclusion: Shockable rhythms in children were rare. Reducing chest compression interruptions by First Aid workers and better consideration of pediatric specifics in the analysis algorithm of AEDs can improve care. The study continues with the collection of survival and neurological outcome data at 1 year.

Background:

Venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) remains one of the main direct causes of maternal death according to the Centre for Maternal and Child Enquiries. The risk of antenatal VTE is four to five folds higher in pregnant versus non-pregnant women. Acute VTE should be suspected in pregnant women with signs and symptoms of DVT and PE.

The subjective clinical assessment is unreliable in pregnancy and only a minority of women with suspected VTE have the diagnosis confirmed with objective testing. Failure to obtain objective diagnosis and subsequent treatment has been attributed to mortality in these patients according to the sequential reports on Confidential Enquiries into Maternal Deaths. Early recognition of VTE and widespread use of low-molecular-weight-heparin (LMWH) thromboprophylaxis until the diagnosis is reached by objective testing can prevent mortality.

Method:

A retrospective study of 46 pregnant patients referred to acute ambulatory care unit with suspected VTE (suspected PE  n=24, suspected DVT n=22) was conducted over a 1 year period.

Patient demographics (age, gestation), signs and symptoms consistent with VTE, predisposing risk factors (Wells score), thromboprophylaxis with LMWH, objective testing with investigations including bloods (d-dimer<250), Chest X-rays, ECGs, Duplex Ultrasound, Ventilation perfusion (V/Q) or CT pulmonary Angiogram (CTPA) scans were analysed.

Results:

The mean age of our pregnant patients was 31 years (18-43). The mean presentation with suspected VTE was at 27 weeks.

21(46%) out of 46 patients were given LMWH thromboprophylaxis prior to objective testing. 25(64%) patients did not receive thromboprophylaxis due to prompt access to radiological imaging, low suspicion index of VTE(negative d-dimer, low Wells score) or maternal refusal until imaging was conducted. 1(2.5%) out of these 25 patients had a positive DVT scan and was commenced on LMWH immediately.

D-dimer was raised in 21(46%) patients, negative in 7(15%) patients but proven positive in 1 patient for a DVT and not conducted in 18(39%) patients given a high index of suspicion for a VTE.

9(37%) patients suspected of having a PE had a CXR and 1(4.2%) CXR was suggestive of consolidation. ECGs were performed in all patients (100%).

Of the 46 pregnant patients with suspected VTE, 5(11%) patients had a confirmed VTE on objective testing. 25(54%) patients underwent a Duplex Ultrasound, 6(13%) underwent a CTPA, V/Q scan was not conducted in any patient. 3(14%) out of 22 patients with suspected DVT had a positive duplex ultrasound. 2(8%) out of 24 patients with suspected PE had a confirmed VTE 1(4%) positive CTPA and 1(4%) positive duplex ultrasound.

Conclusion:

Pregnancy is associated with a hypercoagulable state, increasing the risk of VTE. The subjective clinical assessment of VTE is unreliable in pregnancy and if clinically suspected, treatment with LMWH should be commenced immediately until a definitive diagnosis is reached by objective testing. D-dimer is affected due to physiological changes in pregnancy and should not be relied upon. Radiological objective testing with patient counselling should be considered in all suspected cases to confirm or exclude VTE, leading to appropriate management in these high risk patients. 

Background: It is important to know the factors affecting survival, good neurological outcome and prognosis in patients underwent cardiopulmonary resuscitation (CPR). NR2 (N-methyl-D-aspartate receptor 2) peptide is a plasma biomarkers for acute cerebral ischemia.  In literature, it has not been demonstrated any study assessing NR2 levels in patients undergoing CPR. In this study, we investigated the relationship between the NR2 peptide levels and prognosis in patients underwent CPR in our hospital emergency room.

Method: In the study, the patients with cardiopulmonary arrest (CPA) consecutively admitted to the emergency room and the patients suffer from CPA while being followed in the emergency department, were evaluated prospectively between October 2014 and June 2015. Traumatic, non-traumatic, pre-hospital and in-hospital cardiac arrest patients were included the study. Blood samples for NR2 and other biochemical analysis were  taken during resuscitation. NR2 levels in patients who can provided return of spontaneous circulation (ROSC) and not provided ROSC, and the benefits of NR2 in predicting 28-day mortality were investigated. SPSS ™ ver.16.0 was used for statistical analysis.

Results: A  hundred patients were included in the study but nine patients were excluded from the study due to errors in the blood sampling. Mean age of the patients was 63.6±17.6/year and 64.8% were male. Pre-hospital and in-hospital cardiac arrest percents were 56.0% and 44.0% respectively, and 13.2% of them were traumatic cardiac arrest patients. ROSC was achieved in 60.4% of patients. Between the patients who were achieved ROSC and those who died were detected significant differences in terms of NR2 levels (p=0.004). Although NR2 values of survivors at twenty-eight days were higher than those being exitus, there was no statistical difference (p=0,075). Also in the study,  lactate levels in patients who provided ROSC  and the patients who living 28 days were found significantly lower than those who died  (p=0.02 and p=0.01 respectively).

Conclusion: NR2 levels are increased as an indicator of the ROSC in patients who underwent CPR. This condition is thought to be associated with reperfusion. However, NR2 levels has not been shown to be superior to lactate levels in 28-day mortality prediction.

Background: In-hospital cardiac arrest (IHCA) are often preceded by abnormal vital signs. Preceding abnormal vital signs might lower the physiological reserve capacity and therefore decrease survival after an IHCA.

Aim: To assess preceding national early warning score (NEWS) and its impact on survival after IHCA.

Material and methods: All patients ≥18 years suffering IHCA at Karolinska University Hospital between 1^st January 2014 and 31^st December 2015 were included. Data regarding the IHCA, patient characteristics, NEWS and 30days survival were drawn from the electronic patient records. Parameters included in NEWS were assessed up to 12hrs before the IHCA.  Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with NEWS of 0-4 points (low) versus those with at least 5points (moderate) and high (7 points). Adjustments included hospital site, gender, co-morbidities, first rhythm and place of IHCA.

Results: In all, 358 patients suffered IHCA, of whom 109 (30%) survived at least 30 days. The 87 patients with medium NEWS had a minor chance and those 78 with high NEWS (22%) had a minimal chance of surviving IHCA compared to those with low NEWS (Adjusted OR 0.24, 95% CI 0.12-0.50 and OR 0.08, 95% C.I. 0.03-0.22, respectively).

Conclusion: The NEWS can be a probable proxy for estimating physiological reserve capacity when discussing prognosis with patients and relatives. But even more important, it stresses the need for better preventive strategies in IHCA.

Objectives: 


The outcome of patients after OHCA is poor. Return to spontaneous circulation (ROSC) dramatically decreases with the duration of CPR. Extracorporeal membrane oxygenation has been proposed to assist CPR (ECPR) in OHCA. This study was to investigate the effects and characteristics of ECPR for adult non-­traumatic OHCA versus Non­ECPR on a community­wide basis.

Methods:


A prospective four­-year observational database collected from a community­wide OHCA web registry in an urban EMS (emergency medical services) was studied. The EMS ambulance teams were capable with advanced airway, intravenous (iv) fluid skills, basic and advanced life support and automated external defibrillator techniques. Outcomes included survival and cerebral performance category scale (CPC) at discharge. Adult non-traumatic OHCAs with and without ECPR were compared by regression analysis including factors of patient, pre­hospital and hospital characteristics and outcomes.


Results: 


Comparing OHCA receiving ECPR (n=79) to those without (n=959), ECPR group were younger (median age 56 vs 78, p<0.001) and had higher portion for men (89 vs 64%, p<0;001), witnessed arrest (Wit) (60.8 vs 32.5%, p<0.001), bystander CPR (BCPR) (53.2 vs 36.8%, p=0.005), initial shockable rhythms (SR) (74.6 vs 12.2%, p<0.001) and therapeutic hypothermia (TH) (22.8 vs 1.1%, p<0.001). They (EPCR vs non­ECPR) had no difference for prehospital time intervals (22.5 vs 23 min.), laryngeal mask airway treatment (55.7 vs 52.8%), EMS iv epinephrine (20.3 vs 15.5%), endotracheal intubation (6.3 vs 8.0%), prehospital ROSC (11.4 vs 6%, p=0.09), and ROSC upon hospital arrival (10.1 vs 8.5%). Outcomes were better in ECPR for discharged survival (41 vs 7%, p<0.001) and CPC 1or2 (20.8 vs 3.8%, p<0.001). After adjusting for Wit, BCPR, SR, TH, age and sex, both survival (adjusted odds ratio: 3.6 [95% CI: 2.0­-6.6]) and good CPC 1or2 (adjusted OR: 2.9 [95% CI: 1.2­-6.9]) were still significantly higher in ECPR.

Conclusions:

In current clinical practice for adult non­traumatic OHCA, ECPR tended to apply to patients of younger age, men, witnessed arrest, BCPR, and initially shockable rhythms regardless of positive ROSC upon hospital arrival, that can independently lead to higher survival and good neurological outcome compared to non­ECPR.

Purpose:

Recognition of cardiac arrest with checking carotid pulse is less than a half correct by the public. Poor recognition of cardiac arrest or patient of agonizing situation delays early bystander cardiopulmonary resuscitation (BCPR) that should be critically provided in the first five minutes before emergency ambulance arrival. Globally we still lack of effective technology to assist better recognition of cardiac arrest to facilitate early BCPR and public access defibrillation (PAD). In this study, we aim to innovate a video signals analysis tool to assist recognition of cardiac arrest.

Method:

We designed an innovative skill algorithm for transforming and analyzing the signals of the video recordings filmed with mobile smartphone for part of human body. Fast Fourier Transform (FFT) signals were evaluated in our skill algorithm. The time length for each video recording was fifteen seconds, which was filmed within the first five minutes after cardiac arrest witnessed in the intensive care unit. This signal analysis skill algorithm was applied on the video recordings of cardiac arrest patients and compared with that of normal volunteers.

Results:

We applied our skill algorithm analysis on video segments from twenty cardiac arrest patients (asystole for 18 cases, ventricular fibrillation for 2 cases) and twenty non-arrest volunteers (median heart rate 74/min, IQR: 65-88/min), matched in age and sex. We innovated a mathematic formula to calculate a value (we called it Slope Alfa) mainly from the cluster of FFT signals evaluated by the skill algorithm. The Slope Alfa value (Mean, [SD]) of cardiac arrest patients was significantly different from the value of non-arrest volunteers (0.14, [0.09] vs 1.96, [0.37], p<0.01). The results also indicated a tendency that for cardiac arrest patient the Slope Alfa would be less than 1.0.

Conclusions:

The skill algorithm we innovated for smartphone video signals analysis may successfully recognize patient after cardiac arrest. Further integration of this technology with mobile devices would provide the general public an easily accessible tool for cardiac arrest recognition and early chest compressions.

The Emergency deparments (ED) are very important, among other things,  because are the places where the diagnosis of venous thromboembolic disease  (VTE) that develops on an outpatient basis in most cases is established. It is also where doctors often start specific treatment for VTE and management is decided.

AIM

The principle aim of this study was to evaluate the therapeutic management by emergency physicians of patients diagnosed with VTE in Spanish ED. On the other hand, which is the process of change that has experienced this treatment during follow-up of the patients for six months.

METHODS

The EDITH study is a multicenter retrospective cohort study involving 50 Spanish emergency services belonging to fifteen regions .

We included consecutive patients who were diagnosed with VTE (-PE- pulmonary embolism or deep vein thrombosis -DVT-) and were treated in emergency services between October 13 and December 14, 2014 were included in the study.

We were collected demographic variables, morbidity, risk factors for VTE in the moment of diagnosis , besides the diagnostic and therapeutic management in the emergency department and 6 months later.

RESULTS

A total of 775 patients with VTE were included in the study. 386 patients (49.8%) have PE, with or without DVT. The mean age of patients was 66 years. A 96.9% received anticoagulant therapy in the emergency department, of which 90.6% was LMWH. Only 30 patients in the emergency began acenocumarol and 7 patients received rivaroxaban. At hospital discharge, 65% of DVT and 33.6% of PE remained with LMWH monotherapy. At 1, 3 and 6 months after the stay in the emergency these percentages were maintained for DVT in 42.7, 30.6% and 17.8%, and for PE in 29.2%, 23.1% and 18.9%, respectively. These results are not exclusive to cancer patients but it also observed in all study population. A 73.1% of patients maintained anticoagulant therapy for at least 6 months (83.9% of PE and 61.2% of DVT).

CONCLUSION

A hospital management centered in the use  of  heparins and low transition to antivitamins K in patients with VTE was observed. Similarly, in the outpatient management  the introduction of oral anticoagulants was less than would be expected according to the guidelines of recommendation and a more prolonged duration of treatment it was observed.

Background

Due to the undifferentiated presentation of EVD during the recent outbreak in West Africa, some suspect patients were isolated who subsequently tested negative for the virus. In Sierra Leone, a country in which 69% of healthcare is funded (1) through out of pocket payments, these patients were effectively made destitute as a result of stigmatization and destruction of personal possessions. A number of factors highlighted a need to provide emergency care pathways for these patients. This paper describes the design and implementation of a novel initiative to provide a level of free healthcare to EVD negative patients at Connaught Hospital, the main government hospital in Sierra Leone.

Methods and Findings

Following review of existing global schemes and a consultation period, data was collected from a random sample of 50 patients requiring admission to Connaught Hospital, after presentation to the A&E, in order to estimate routine aggregate costs for investigations and medical treatment. This data was used to set a funding cap of 260,000 Leones (approx GBP £35), which was calculated to provide free investigations and treatment for 98% of cases. In total, free care was provided to ~300 eligible patients over a 6 month period. The major boundaries to implementation were absence of strong patient advocacy, and lack of hospital resources: both preventing patients receiving the full complement of prescribed services.

Conclusions

In resource-poor settings such as Sierra Leone, where free healthcare is provided in incremental packages alongside the existing out-of-pocket payment system, it is essential for successful implementation that new initiatives are embedded within existing systems. This paper presents a number of lessons learned in the design and implementation process of a novel capped free healthcare system and proposes an extended approach to provide on-going tertiary care to EVD survivors and other vulnerable groups in Sierra Leone. This work also proposes a generalizable mechanism to support patients and strengthen healthcare systems in the transitional phase that follows other such humanitarian crises.

Introduction: Injuries are a major cause of morbidity and mortality in both developing and industrialized regions ¹.  Injury severity scores are simply a way to describe and quantify the severity of traumatic injury and also provide some sense of the probability of survival of the victims². The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury ³.This study aims at evaluating the component of trauma triage tool with highest positive predictive value to identify major trauma patients.

Objective:

To determine the component of pre-hospital tool (Trauma Triage tool) with highest positive predictive value?

Methodology:

 A Retrospective database analysis of Major trauma patients presenting to QEHB during the period January 2013 to January 2014 was performed. All Major trauma patients (TTT positive) presenting to QEHB during this period were included.  The patients who were TTT Negative were excluded.

Data were coded and entered on Excel file and statistical analysis was done using the Statistical Package for Social Science (SPSS) version 16.0. Descriptive analysis was conducted to determine the sensitivity and specificity of pre- hospital TTT and each of its components (vital signs, anatomy, injury mechanism and special conditions). Pearson Chi- Square test, Fisher’s exact test and Independent Student's t- test were used to evaluate the association between the severity of injury and certain variables: Mechanism of injury, Glasgow Coma Score (GCS) level and patient's age.

Results:

There were 694 trauma patients presented during study period. Only 597 patients met the inclusion criteria and were included in the study. The majority of our sample was male (70.7%), with a mean age of 53 years. About one third of these patients had involved in RTCs. Approximately 60 % of the study group had been alerted in as major trauma cases.

Out of the 597 trauma patients, 316 patients were identified as a major trauma cases (true positive cases) that had an estimated ISS more than 15 (Positive Predictive Value (PPV) = 0.529 at 95% CI 0.49, 0.57; p= 0.000).

The Trauma Triage Tool consists of four components: Vital signs, Anatomy, Mechanism of injury and Special conditions. The Physiology component had the highest PPV of 0.79 at 95% CI 0.73, 0.85, which was followed by the Mechanism of injury with PPV equals 0.618 at 95% CI 0.55, 0.69, then the Anatomy component (PPV= 0.523 at 95% CI 0.46, 0.69), then the Special conditions components which had PPV of 0.448 at 95% CI 0.39, 0.51.

Conclusion:

Within the pre-hospital management of seriously injured trauma victims the accuracy of the field triage is of utmost importance. The clinicians significantly depend upon the pre hospital information to activate the resources.  Hence greater the PPV of TTT better the trauma team remix can be planned.

Our results clearly suggest the correlation of abnormal physiological parameters with high probability of ISS>15. Even when combined with other components of the TTT the PPV of the physiological component remains the highest.

Background

In 2005, 2013 and 2015 respectively, London, Boston and Paris (November events for this study) were targeted by major terrorist attacks. Despite their differences these attacks caused many common difficulties and issues for rescue organizations in countries with mass casualty plans that differ widely. The aim of the present study was to analyze and compare the specific responses of each city to a similar kind of crisis.

Participants and methods

We used publications and official reports about the London bombings [1], Boston bombings [2] and Paris terrorist attacks [3,4]. We detailed, when available, response timelines for each attack, the resources committed, the pre-hospital organization and hospital dispatch. 

Results

In London, 4 suicide-bomb attacks (3 aboard London Underground trains and 1 on a double-decker bus) killed 52 civilians and injured over 700 more. In Boston, 2 pressure cooker bombs placed near the finish line of the Boston marathon killed 3 civilians and injured 264 more. In Paris, suicide bomb attacks, mass shooting and hostage taking killed 130 civilians, including 89 on one closed site of mass shooting, and injured over 413 more. Three different dispatch strategies were used: proximity dispatching in London, equal pre-defined dispatching in Boston and regional partially medical dispatching in Paris. If not already activated, national crisis management facility was operational in less than 40 minutes. 7 to 17 hospitals were involved in caring the victims. In all cities, evacuation of the victims was achieved in less than about 6 hours after the beginning of the attack.

Discussion

Several key points can be extracted from the three responses. A pre-defined idea of the capacities of each hospital as well as a real-time assessment proved extremely helpful. A unique dispatch and control center allows a good overview of the destination of the patients. Dedicated communication channels between all the critical national infrastructures allow swifter alert of all the involved services. Good communication is always a major issue, particularly in areas where networks are saturated, switched off, degraded or destroyed. When the network is on, giving the right information to the right persons at the right time is both vital but very difficult. Mass casualties require material, vehicles and personnel in numbers that need to be organized in advance if we want to respond without delay. Dealing with the uncertainty of the situations and reacting quickly requires response systems that are simple and robust and that favor the autonomy of the operational teams. Finally, drills, exercising, and repeating procedures again and again are absolutely crucial if we are to be agile and effective in our responses. 

1. Report of the Official Account of the Bombings in London on the 7th July 2005

2. After Action Report for the Response to the 2013 Boston Marathon Bombings, dec 2014

3. Hirsch M et al., The medical response to multisite terrorist attacks in Paris, Lancet 2015 Dec 19;386(10012):2535-86.

4. Lesaffre X, Attacks on Paris: what can we learn, oral presentation

Introduction:

Triage, the process of categorising patients based on clinical acuity, is a key principle in the effective management of a major incident (MI).  There are at least three different triage systems in use worldwide, and previous attempts to validate them have demonstrated limited performance. 

Using a military cohort and regression analysis, the Modified Physiological Triage Tool (MPTT) was developed and when compared to existing triage methods, demonstrated an improved performance at predicting need for life-saving intervention and yielded the lowest rate of under-triage (30.1%).  Within the adult civilian population, where blunt trauma predominates and there is an older population, no such work has been undertaken to develop an improved system of triage.

The purpose of this study was to perform a comparative analysis and initial validation of the MPTT within a civilian environment. 

Methods:

A retrospective review of the Trauma Audit Research Network (TARN) database was performed for all adult patients (>18 years) presenting to a UK Emergency Department (ED) between 1 January 2006 and 31 December 2014. Patients were defined as Gold Standard Priority One if they had received one or more life-saving interventions from a previously defined list.  Only patients with complete physiological data and who received treatment at a single hospital were included in the analysis.

Using first recorded physiological data (HR/RR/GCS/SBP), patients were categorised as Priority One or Not Priority One by the newly derived MPTT (12 > RR < 22, HR > 100, GCS < 14) and existing major incident triage tools (START - ST, CAREFLIGHT - CF, Modified Military Sieve – MMS and Triage Sieve – TS). Performance characteristics of all triage tools were evaluated using sensitivity, specificity and AUROC, and rates of over and under-triage were compared. AUROC were compared for triage tools with similar performance.

Results:

The TARN registry held records for 218,453 adult patients during the study period, of which 129,647 (59.3%) had complete data and were included in the analysis.  55% of patients were male, with a median age of 61 (range 18-111).  25,452 patients (19.6%) were defined as Priority One, with a median ISS of 9.  Blunt trauma predominated (96.5%), with falls < 2m the most common injury mechanism (53.9%).

The MPTT outperformed all existing triage methods with the highest sensitivity (58.1%) and demonstrated an absolute reduction in under-triage of 44.5% when compared to the existing MIMMS Triage Sieve.  With an AUROC increase of 1.3, ROC comparison demonstrated significance between the MPTT and MMS (c² = 83.91, p < 0.001), statistically supporting the use of the MPTT.

Conclusion:

This study has defined the performance of the MPTT (a tool derived using a military cohort) in a civilian environment, where it has been shown to outperform all existing MI triage systems in its ability to predict need for life-saving intervention.  As a result of this validation, its use within a civilian major incident context is recommended.

Background: Chances of survival in out-of-hospital cardiac arrest (OHCA) patients decrease with increasing duration of hypoperfusion. The pathophysiological changes after prolonged resuscitation efforts and consecutive hypoperfusion appears comparable to those in severe sepsis leading to post-resuscitation coagulopathy. The occurrence of overt disseminated intravascular coagulation (DIC) is associated with poor outcomes and high mortality risk in various medical conditions. Similarly, the occurrence of DIC in cardiac arrest patients seems to be associated with an unfavorable prognosis. 

Objective: Recent data suggest an overt DIC rate of 33% in OHCA patients with sustained return of spontaneous circulation (ROSC). The current study determined the prevalence of overt DIC, its association with outcome, and the predictive value of d-dimer in an Austrian collective of OHCA patients.

Methods: All patients with available coagulation parameters from 2006-2014 were extracted from a prospectively compiled OHCA registry. Primary outcome was the prevalence of overt DIC. Binominal logistic regression analysis was applied to ascertain predictors of overt DIC, 30-day mortality and neurologic outcome. The discrimination of the fitted logistic models was assessed using the area under the receiver-operating-characteristic (ROC) curve.

Results: Out of 1179 OHCA patients, coagulation parameters were available in 410 (72% male; 57years, 48-69). The rate of overt DIC was 10% (95%CI, 7-13; n=39) overall and 7% (95%CI, 5-10; n=30) in the sustained ROSC subgroup. The odds ratio for 30-day mortality (46%, 95%CI 41-51; n=188) increased with the DIC score and was 9.6 (crude OR; 95%CI, 3.7-25) in patients with overt DIC on admission (n=39). The regression model including d-dimer, lactate levels, no-flow interval and initial rhythm (χ2(4)=125.1; p<0.001; HLT=0.20) best predicted 30-day mortality (R2= 0.58); The inclusion of d-dimer levels into the model significantly increased the area under the ROC curve from 0.78 (95%CI, 0.73-0.85) to 0.90 (95%CI, 0.85-0.94; p=0.001).

Conclusion: The current study identified increasing no-flow intervals (indicating the extent of non-perfusion), a non-shockable initial heart rhythm and elevated lactate levels (indicating the magnitude of tissue hypoxia) as the main predictors of overt DIC patterns in OHCA. The inclusion of d-dimer levels into a prediction model, however, improved its accuracy, and d-dimer levels may serve as an additional, independent surrogate parameter to assess outcome in OHCA.

Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures

Objectives: To evaluate the willingness to work of hospital staff and factors promoting it  in different mass casualty settings.

Background: When disaster strikes, getting care to the victims is at the top of everyone's attention. But who will provide that care? A part of the hospital personnel will be absent as they are inflicted in the incident whereas the management expects that the rest deploys a higher engagement to cope with the surge. However, care for inflicted family and fear of becoming a secondary victim could prevent people to go to work.

Material and methods:

4 groups (physicians, nurses, administration and supportive services) in Belgian hospitals were presented an online questionnaire checking for demographics, knowledge of and intention to work in 11 potential MCI disaster scenarios.

Results:

The Ebola outbreak, a train derailment with toxic release and the Paris / Brussels attacks raised national awareness which allowed us to score in 18 hospitals after the 7 hospital pilot. Ten more are ready to join giving a nationwide coverage.

Preliminary results reveal an overall highest response rate in the physician group where more than 1/3 works unconditionally. The supportive services score second best (27%) followed by the nurses (22%) and administration (21%). Highest response rate in all groups is found in seasonal influenza epidemics (54% works unconditionally). Ebola has the lowest rate of unconditional response (13%). Incidents where people will not respond to work, even with the risk of losing their job, are Ebola and nuclear incidents (9.5% and 8.8% respectively).  Since the West African Ebola outbreak, there is a clear downwards trend in willingness to work in these circumstances.

The majority of personnel will work under conditions. Factors that convince people to respond are in order of importance: availability of appropriate personal protective equipment, free availability of preventive medication or antidotes, insurance that family is safe, regular feedback on the evolution of the incident, previous training and communication channels with the family.

Conclusion:

Hospital managers should be aware that just a part of their personnel would come to work unconditionally in case of a disaster. Local evaluation can help identifying promoting measures to maximize response.

Background and purpose

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighbouring countries led to the influx of many asylum-seekers in some European countries, including Belgium.

This study aims to document demographics of asylum-seekers arriving in a refugee camp in Brussels in September 2015 and to describe diagnoses and comorbidities of patients presenting to a Field Hospital.

The study hypothesis is that among asylum-seekers in a huddled refugee camp – even in a well-developed country with all medical facilities – respiratory, digestive and other medical problems typical of refugee camps wherever in the world, will emerge soon.

Patients and methods

Using a cross-sectional observational study design, physicians of Médecins du Monde prospectively registered age, gender, origin, medical complaints and diagnoses of all patients presenting to an erected Field Hospital in Brussels in September 2015. Diagnoses were post-hoc categorised according to the International Classification of Diseases. Of 4037 patients examined, 3907 were included and analysed for this study: 86% were male, median age was 28 years (range 0-93;IQR 12), and patients came from 63 different countries, mostly from Iraq (52%), Syria (20%), Morocco (10%), Afghanistan (3%), and Palestine (3%). Some 1% were stateless.

Results

The most common primary diagnoses were upper respiratory tract infections (31%), dental caries (8%), skin infections (8%), gastroenteritis (7%), skin wounds and burns (6%), musculoskeletal disorders (6%), and accidental trauma (6%). Mental disorders were present in 2%. One per cent was victim of intentional violence in the country of origin, or during the journey to Brussels. Two women had just delivered and five new-born babies attended, of which one had to be hospitalised for bronchiolitis with severe dyspnoea.

When classified, the most frequent diagnosis categories were respiratory disorders (36%), far ahead of injury (12%), dental (10%), skin (9%), digestive (8%), and musculoskeletal diagnoses (6%).

Comorbidities consisted mainly of arterial hypertension and diabetes. Referrals were organised for 11% patients to dentists (5%), to Emergency Departments (3%), to psychotherapists (2%), and to new-born care (1%).

Features of infection were found in 49% of patients, with an even higher proportion (63%) in children younger than 5. A multiple logistic regression analysis indicates that the risk of being infected is significantly higher for asylum-seekers from Syria and Iraq, and for children.

Conclusions

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from respiratory, dental, skin and digestive diseases, and one of seven is injured. Half of this population shows features of infection; with asylum-seekers from Syria and Iraq, and children being most vulnerable, urging even developed countries to take measures to prevent the spread of infections. Early shelter, overcrowding reduction, adequate sanitary facilities, and accessible healthcare may avoid short and long term complications, leading to higher healthcare expenditure for the hosting population.

These findings should be anticipated when composing Emergency Medical Teams and Interagency Emergency Health Kits to be used in a Field Hospital, even in a Western European country.

Background and purpose

The civil war that started in Syria since 2011, led to one of the most complex humanitarian emergencies in history. This ongoing disaster, in which warring parties deliberately target healthcare infrastructure and services, has detrimental consequences affecting the health of children as one of the most vulnerable populations.

The purpose of this study is to document the medical threats, comorbidities, diagnoses and disease categories in Syrian children after four years of conflict, and estimate the need for relief efforts needed to provide efficient medical care to Syrian children.

Patients and Methods

A cross sectional observational sample study was conducted in May 2015. By means of a prospectively designed medical registry, Qatar Red Crescent healthcare workers especially trained for this study, collected demographic information, comorbidities, and diagnoses in children visited home by home and in internally displaced persons camps in four Syrian governorates. Diagnoses were post-hoc categorised according to the ICD-10 classification.

Of 1080 filled-out records, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

Results

Most primary acute diagnoses in examined children were upper respiratory tract infections (14%), lower respiratory tract infections (9%), gastroenteritis (8%), suspected meningitis (7%), asthma (6%), convulsions (6%), eye infection (5%), clinical anaemia (5%), and skin infection (5%). Four per cent showed signs of malnutrition, some children had been victim of injury (3%) or violence (1%), and 2% of children suffered from a mental disorder.

When categorised according to ICD-10, most children suffered from respiratory (29%), neurological (19%), digestive (17%), eye (5%) or skin (5%) diseases, 4% was injured, and 2% suffered from a mental disorder. Overall, 55% of patients had features of infectious diseases.

Most common chronical illnesses were mental health diseases (25%), epilepsy (11%), malnutrition related conditions (5%), and flaccid paralysis (4%).

Statistical analysis indicates that the risk for children to suffer from infectious diseases is significantly higher when they reside in Aleppo or Idleb. The risk of being injured is significantly higher in Aleppo, while intentional violence is most occurring in Lattakia. Mental problems are more prominent in Hamah. These problems are not linked to gender or age, except for infectious risks: younger children are more at risk to have an incomplete vaccination state, and suffer more from preventable dangerous infections.

Conclusions

After years of civil war, more than half the children in Northern Syria suffer from infections, mostly from respiratory, neurological and digestive origin, while 4% is injured or victim of dirty weapons.

Substandard paediatric healthcare circumstances and worsening vaccination state put Syrian children at risk for serious infections, outbreaks and morbidity, and should be urgently addressed by humanitarian relief efforts.

An immediate coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of health threats for children in Syria.

BACKGROUND AND PURPOSE

The Syrian civil war since 2011 led to one of the most complex humanitarian emergencies in history. This protracted disaster has but negative aspects, especially on children.

Purpose of this study is to document the impact on the social, educational and public health state of Syrian children.

PATIENTS AND METHODS

A cross sectional observational sample study was conducted in May 2015. Healthcare workers, especially trained for this study, visited families home by home with a prospectively designed questionnaire in four Northern Syrian governorates.

Of 1080 filled-out questionnaires, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

RESULTS

Almost 20% of children were Internally Displaced Persons. The father was deceased or missing in respectively 5% and 4%, and similarly for the mother in 2% and 3% of the children. Almost 15% had no access to safe drinking water, and 23% could not access appropriate sanitation. About 16% had insufficient access to nutrition, and almost 27% suffered from malnutrition. Access to specific mother and child healthcare providers was disturbed in 64%, and vaccination state was inadequate in 72%. More than half of all school-aged children had no access to education at the time of the study.

Statistical analysis indicates that the risk for children to have unmet depends mainly on the governorate in which they reside. Most affected governorates are Idleb and Lattakia for water, sanitation, education, and healthcare; and Aleppo for missing vaccines. These problems are not linked to gender or age, except for the vaccination state: the smaller the children, the more they are at risk to have an incomplete vaccination state.

CONCLUSIONS

After four years of civil war in Syria, many children have lost their parents, are being displaced, and live in substandard life quality circumstances. Most children miss education, undermining their own future and that of the country. Limited access to water, sanitation, and to regular and healthy food, together with increasing malnutrition rates, worsening of the immunisation state and accessibility to specific healthcare facilities add up to the factors that put Syrian children at risk for increased morbidity and mortality.

Urgent coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of social, educational and public health threats for children in Syria.

Background: The number of emergency department (ED) visits by the elderly is increasing. Cognitive impairment is a risk factor for functional decline and mortality but its assessment takes too much time in older patients in the Emergency Department. Information about cognition at arrival might be of great value to assist clinicians in making treatment decisions, to detect risk of delirium in an early phase and to reduce the risk of adverse health outcomes by implementing targeted interventions. Therefore, the aim was to investigate if the relatively brief Six-Item-Cognitive-Impairment-Test (6-CIT) is an independent predictor of functional decline and mortality, a pre-requisite to be used as a screening-tool in the acute setting.

Methods: A multicentre prospective observational follow-up study was conducted in patients aged 70-years or older, visiting the ED of the Leiden University Medical Center (LUMC) and Alrijne Hospital in the Netherlands. At baseline, the Six Item-Cognitive-Impairment-Test (6CIT) and functional status, as assessed with the Katz-ADL, was assessed. Cognitive impairment was defined as a 6CIT score ≥11. Multivariable logistic regression analysis with the primary outcomes mortality and functional decline (composite endpoint adverse outcome), at three and twelve months (LUMC only) after the ED visit was used.

Results: 1632 patients were included (LUMC n=751, Alrijne n=881). 326 patients (21.4%) had cognitive impairment. Compared to normal cognition, cognitive impairment is associated with increased risk of adverse health outcomes, independent of age, sex, education and triage urgency, with corrected odds ratios of 1.87 (95%CI:1.42-2.46) at three months. Patients with impaired cognition had increased risk of mortality after three and twelve months (HR 2.27(95%CI1.54-3.34)).

Conclusion Cognitive impairment, measured with the 2-3 minute 6CIT, is independently associated with adverse health outcomes in older ED patients.

Background:

As a result of demographic transition, the proportion of « very elderly » (≥ 90 years) patients is increasing worldwide and more of these patients are nowadays admitted to intensive care units (ICU). Among physicians the discussion about appropriateness of these ICU admissions still remains controversial. mostly due to questionable outcome, limited ressources and costs. The aim of the study was to determine and evaluate the clinical characteristics and outcome in a very old population admitted to a medical ICU in an urban hospital.

Methods:  

We present here a retrospective and monocentric study. We reviewed the charts of all patients (≥ 90 years) admitted to a medical ICU between 2005 and 2015. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the ICU stay. A long-term survival follow-up was also performed. 185 patients were included for statistical analysis.

Results:

A total of 185 patients were included, which represented 1.8% of admissions to the ICU during this 10 year period. The mean age was 92.7 +/- 2.2 years, the sex ratio was 0.34. Most of patients (39%) were admitted from the emergency department (ED) and 34% directly from pre-hospital care (EMS). The mean Charlson comorbidity score was 7.6 (95% CI: [7.3-7.8]) and the mean McCabe score was 1.36 (95% CI: [1.28-1.43]). The admission diagnosis in the ICU was mainly respiratory distress (48%), septic shock (13%), coma (11%) and cardiac arrest (10%). The average SAPS-II score within 24 hours of ICU admission was 58.1+/-23.2. 20% of these patients suffered of previous dementia. 50% of patients required support by mechanical ventilation (mean duration 7.1 days) and 6% of patients received renal replacement therapy. ICU and hospital mortality rates were 40% and 46% respectively. Overall survival at three months after hospital discharge was 48%. For 34% of these patients, a limitation of active treatment was decided (on average after two days of stay). For 66% there was no justification for limiting care because of a well-established treatment plan (with family, GP, ICU team).

Conclusion:

The proportion of elderly patients remains low, but they are increasingly being treated in intensive care units. The in-hospital mortality is high (40%) compared to the average mortality in our ICU over the same period (20%). The prognosis is often not as poor as perceived by physicians. The indication for ICU treatment in our study was mostly justified ; in the setting of  consistent patient care and good clinical practice. It remains therefore appropriate to discuss every ICU admission of elderly patients without any restriction related to age.

Background:

During the past decade emergency medicine evolved to an increasing challenge for clinics of all stages of patient care due to a substantial and continous change of medical knowledge, limits of time and health care economics as well as an enormous rise of patient cases. Thus, continuous medical education for all employees involved in the preclinical or clinical phase of emergency care represents an essential prerequisite for high quality patient-centered care to overcome these problems. However, in this special setting of rush, stress and highly intense workload conventional learning techniques do not allow for continous training on the job. To address this problem we developed novel learning and teaching strategies based on digital technologies for both academic and non-academic staff members within interdisciplinary emergency care departments (ED).

Methods:

For medical students and trainees we created a podcast and an emergency care software for simulation of emergency cases in order to prepare for the work within the ED in comparison to control groups without access to these learning tools. Acceptance, frequency of usage and effects of these techniques were assessed prior to and after the occupation within the ED by standardized questionnaires and tests. For nurses and paramedics we first assessed the information demands during all processes of emergency patient care in the preclinical and clinical phase. Based on these needs intelligent assistance services were established in cooperation with two technological partners to support daily workflow via web-based services.

Results:

Introduction of the podcast and the emergency care software prior to the start within the ED resulted in a significant improvement of skills and expert knowledge for both medical students and trainees in comparison to the control groups (p< 0.002). Both innovative tools were widely accepted and frequently used by each proband. Analysis of processes within the preclinical and clinical phase of emergency care revealed information demands for paramedics and nurses especially with respect to invasive/non-invasive techniques, first aid standard operating procedures, medications and medical devices. Content for these assistance services was developed and subsequently digitalized for web-based usage via mobile devices (tablets). Preliminary results of these applications will be demonstrated and evaluated in a pilot study.

Conclusions:

Introduction of novel learning and teaching strategies within the ED allows for a continuous medical education and training on the job in the special setting characteristics of emergency care. Results of our studies revealed a significant improvement of technical skills and medical expertise thus leading to a better performance of the academic staff within the ED. Further studies with non-academic employees now have to evaluate the effects of these innovative strategies within the preclinical and clinical phase of emergency care.

Background: Confusion in elderly people presenting to Emergency Department (ED) is often associated with a state of agitation with or without aggressivity. Recommendations for the management of these patients exist. Physical restraint (PR) is sometimes necessary to protect them but it is a source of morbidity and mortality. The aim of our study was to examine how emergency physicians prescribe physical restraint for elderly people presenting to ED. The primary outcome was association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR.

Methods: Elderly people (age > 75 years old) with prescription of PR were included in this retrospective study between november 2014 and march 2015 in Lariboisière University Hospital, Emergency Department . Two groups were compared on such criteria: 1 / PR alone (group A); 2 / PR + chemical treatment (group B). The primary outcome was the association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR. The secondary outcomes were justified prescription of PR, revaluation of the indication of PR and monitoring of the PR. The student test was used for quantitative variables. The Chi 2 test was used for qualitative variables.

Results: One hundred thirty-eight consecutive patients were analyzed (66 [48%] in group A and 72 [52%] in group B) with no significant difference between the 2 groups (p = 0.32). The prescription of benzodiazepine associated with PR was significantly higher compared to the prescription of neuroleptic. The number of justified prescription of PR was higher but not significantly different (p = 0.05) in group B (n = 18 [25%]) than in group A (n = 8 [12%]). Half of justified prescription of PR was linked to an act of nursing care. The daily revaluation of the PR was significantly higher in group B (respectively 11 [15%] vs 0 in group A, p <0.01).

Conclusion: Elderly people having PR did not always have an associated chemical treatment as provided by the recommendations. The prescription of PR were insufficiently justified. The daily revaluation of the indication of the PR and clinical-biological monitoring were almost non-existent causing a risk of increased morbidity and mortality. This study justified the establishment of a protocol to guide the prescription of the PR in elderly people in our ED.

Introduction

Elderly patients are at particular risk of experiencing adverse events of hospitalisation, and they are more vulnerable to adverse events compared to younger patients. The aim of this study was to compare the occurrence of adverse events during hospitalisation or within 30 days after discharge to either a short stay unit or a department of internal medicine in elderly internal medicine patients.

Methods

This retrospective study evaluated adverse events during hospitalisation of elderly internal medicine patients either in an emergency department based short stay unit called ‘Quick Diagnostic Unit’ (QDU) or an internal medicine department (IMD) at Holbaek Hospital, Denmark, from January 1^st 2014.. Eligible patients were 75 years or older and admitted for any internal medicine disease and they should have a non-emergent (green) triage level at admission. IMD patients were matched with QDU patients by 1) year of birth and 2) date of admission. Medical records were reviewed in a two-stage process by physicians to detect adverse events. Earlier studies have shown that up to 37 % of elderly patients experience an adverse event during a hospitalisation; to detect a 33 % risk reduction based on alpha=0.05 and beta=0.08, a sample size of 450 patients was required. The primary outcome was the occurrence of any adverse event on a list of 19 predefined events during hospitalisation or up to 30 days after discharge. Secondary outcome measures included types of adverse events and mortality. A p-value <0.05 was considered significant.

Results

We screened a total of 833 patients’ hospital charts for inclusion and 450 patients met the inclusion criteria, 225 patients in each group. The median age of patients were 82 years (IQR 78-86 years) for both groups. There were no significant differences in baseline variables. For both groups, the median Charlson Comorbidity Index score was 6 with IQR 5-7. Adverse events were significantly less common in the QDU-group than in the IMD-group, i.e., 68 (30 %) patients in the QDU-group and 92 (41 %) patients in the IMD group had one or more adverse events of hospitalisation, (p=0.02). The relative risk of an adverse event was 0.80 (95 % CI 0.65-0-99) in the QDU-group and 1.23 (95% CI 1.02-1.15) in the IMD group, respectively. The most common adverse events were 1) transfer during hospitalisation, 2) unplanned readmission, 3) nosocomial infection in both groups. We found no significant difference in 90-day mortality QDU-group compared to the IMD-group, 65 (29 %) versus 84 (37%) (HR 0.729 (95% 0.414-1.284)).

Conclusions

Adverse events was significantly less common in elderly patients treated in a medical short stay unit compared to an internal medicine ward. Hospitalisation in a short stay unit seems not only feasible, but in selected cases maybe even preferable, for elderly medical patients.  

Introduction: Elder abuse is a significant public health problem. The population of elder people is increasing steadily. According to World Health Organization (WHO), by the year 2050, it is expected that the number of elder people would have come up to 20 percent of world population. Although the elder abuse and neglect prevalence is higher than supposed, it is much lower to identify and report these cases, especially in emergency medicine departments. The aim of this study is to assess the knowledge and attitudes of emergency medicine health care professionals toward the identification and management of elder abuse and neglect cases.

Methods: This cross-sectional descriptive study was performed in two universities and two training and research hospitals’ emergency departments in Ankara.  The research tool was a 26-item questionnaire that was applied on 184 emergency medicine health care professionals including doctors, nurses, emergency medicine technicians.  Analysis was completed with SPSS 15.0. In addition to descriptive statistics, chi square analysis were used to determine differences between groups.

Results: Although 78% of participants had identified an abuse elder person before, 64% of them have never reported about elder abuse. The main reasons of not reporting are not to feel proficient (41%) and not know how to do that (27%). Significant percent of responders answered that they haven’t had any education about elder abuse and neglect in undergraduate education (73%) and post-graduate education (87%).

Conclusion: This study indicates that emergency medicine health care professionals confronts with abused elder frequently but they abstain from reporting these cases because they feel lack of knowledge about elder abuse and neglect especially.

References:

1. Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Archives of Gerontology and Geriatrics 43 (2006) 267–276.
2. Fulmer T, Paveza G, Abraham I, Fairchild S. Elder neglect assessment in the emergency department. Journal of emergency nursing: 2000 vol: 26 (5) pp: 436-443.
3. Almogue A, Weiss A,  Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Archives of Gerontology and Geriatrics 51 (2010) 86–91.

Acknowledgements: There is no funding received for this work from any organizations. The authors declare that they have no conflict of interest.

Background: The traditional model of education in medical schools is based on the belief that students will successfully transfer knowledge gained in classroom lectures, completed by self-education trough e-learning. More educational programs are also starting to integrate simulation based learning into their teaching methods. Several studies suggest that clinical simulation is an effective teaching strategy, although it is very depending on the context, topic and method.  Finding out what is the most impactful methodology leading to the best learning and knowledge retention over time is desirable.

The present study was designed to evaluate the added value of virtual simulation programs in teaching START triage to medical students, compared with e-learning and classroom teaching.

Methods: Twenty medical students were randomly assigned into two groups: group A and group B. Both groups were given the same classroom lecture, supported by a PowerPoint presentation on how to perform START triage in Mass Casualty Incidents (MCI). Immediately following this lecture, a 30-item paper-based test was administered to assess the student’s ability to understand and apply START triage.

Both groups received a more extensive online presentation with examples and video’s through e-learning. Group B had an additional interactive session with virtual simulation training and professional feedback.

One month later a new test was given to assess and compare knowledge between both groups.

Simple descriptive statistics were used to analyse findings, with the independent samples T-test to compare groups where appropriate. For further analysis nonparametric statistics were used due to some indications of possible non-normality.

Alpha was set at p < 0,05 to determine statistical significance. All analyses were conducted using SPSS® software.

Results: The baseline test showed a mean score of 15,65 out of 30. For the second test, taken after the thirty-minute classroom teaching session an average score of 26,15 out of 30 was observed. This statistically significant change (Independent‐SamplesMann‐Whitney‐U test, p < 0,001) showed a strong improvement in knowledge after a brief classroom teaching session. After one month of e-learning group A had an average score of 28,6 out of 30. Group B, who received the additional virtual simulation session, scored 28,875 out of 30.

This result didn’t reveal any statistically significant difference between both groups (Independent-Samples Mann-Whitney-U test, p = 0,696).

Also examined was the number of over- and undertriaged casualties, but no significant differences were found between either group. No differences between men and women were noted.

Conclusion: Although virtual simulation training has been described in literature as an effective teaching strategy, no significant differences in scores on knowledge tests were found between two test populations of which one received ‐ in addition to classroom lecture and e‐learning ‐ a computer‐based virtual reality simulation training.

Nevertheless, certain findings in this study were surely intriguing opportunities for further research. A comparable study with a larger test group, a more extensive teaching subject and/or a longer time interval between the tests could be interesting pathways to investigate.

Background: Simulation is defined as a technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. The use of simulation in emergency medicine began decades ago with the use of low-fidelity simulations and has evolved at an unprecedented pace. The literature on simulation is abundant in emergency medicine. But the methodological quality of these studies had not yet been assessed. The aim of this study was to conduct a systematic review of published randomized controlled trials (RCT) assessing a simulation intervention and to examine their methodological characteristics.

Methods: We performed a systematic review on MEDLINE via PubMed of randomized controlled trials, assessing a simulation intervention, published from January, 1^st 2012 to December, 31^th 2015 in the 6 general and internal medicine journals, and the 10 emergency medicine journals with the highest impact factor according to the Institute for Scientific Information Web of Knowledge. Two researchers independently performed the trials selection and extracted the data, if necessary a third researched stepped in to resolve disagreements. For each trial, researchers extracted the RCT general characteristics, the participants, intervention, comparator and outcomes as reported in the trial report. The Cochrane Collaboration risk of bias tool was used to assess the trials risk of bias, using the tool main domains (sequence generation, allocation concealment, blinding of participants, blinding of outcome accessors, incomplete data management and selective reporting). Methodological quality was evaluated using the MERQSI score. The MERSQI is a tool used to assess educational interventions.

Results: 1 394 RCTs were screened, 270 (19%) were considered as in the field of emergency medicine and 69 (26%) assessed a simulation intervention. Fifty-five RCTs were monocentric. The average time of acceptance was 143 days (SD=86). Studies included on average 144 participants. United States of America were the most frequent place of study. In included trials, cardiopulmonary resuscitation (CPR), was the most frequent topic (n=55; 80%). The usual procedure was the comparator in half studies (n=37). 30 (43%) of RCTs were evaluated for CPR quality outcomes. A total of 10% (n=7) were registered on a public registry or had an available protocol. The random sequence generation and allocation concealment were correctly performed respectively in 68% (n=47) and 43% (n=30).The participants and assessors blinding were correctly performed in 20% (n=14) and 62% (n=43). The attrition bias was low in two-third in studies (n=50). The reporting bias was low in nearly all studies (n=65; 95%).Methodological quality by MERQSI score averaged 12.3/18 (SD=3).

Conclusions: Trials assessing simulation count fo one quarter of published RCTs in emergency medicine. Their quality remains unclear and should make us very cautious when interpreting their results. In our sample authors particularly failed to correctly describe the blinding and allocation concealment. These trials characteristics being associated with the magnitude of the intervention effect based on previously published meta-epidemiological studies.

Introduction:

Characteristics of older frequent users of Emergency Departments (EDs) are poorly understood. Our aim was to examine the characteristics of the ED frequent attenders (FAs) by age (<65 and ≥65 years).   

Methods: 

We examined the prevalence of FA attending the ED of an urban teaching hospital in cross-sectional study between 2009 and 2011. FA was defined as a person who presented to the ED four or more times over a 12-month period. Randomly selected groups of FA and non-FA from two age groups (<65 and ≥65 years) were then examined to compare characteristics between older FAs and non-FAs and older FAs and younger FAs. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals for 12-mortality in FA compared to non-FA aged ≥65years.

Results: 

137,150 ED attendances were recorded between 2009 and 2011. 21.6% were aged ≥65years, 4.4% of whom were FAs, accounting for 18.4% of attendances by patients over 65 years. There was a bi-modal age distribution of FA (mean ±SD; <65years 40±12.7; and ≥65years 76.9±7.4). Older FAs were 5 times more likely to present outside normal working hours and 5.5 times more likely to require admission. Cardiovascular emergencies were the most common complaint, in contrast with the younger FA group, where injury and psychosocial conditions dominated. The OR for death at 12-months was 2.07 (95% CI 0.93, 4.63), p=0.07, adjusting for age and gender. 

Conclusion:

1-in-5 ED patients over 65years are frequent attenders. Older FAs largely presented with complex medical conditions. Enhanced access to expert gerontology assessment should be considered as part of effective intervention strategies for older ED users.  

Introduction

Recent data suggests >2/1000 people live with HIV in the Dublin area. British HIV Association guidelines advise universal HIV testing at this threshold. Reported prevalence of Hepatitis C (HCV) in Ireland is 0.5- 1.2%. Hepatitis B (HBV) prevalence is unknown. The aim of this study was to assess the feasibility of a HIV, HBV and HCV panel screening programme in an urban Emergency Department (ED).

 Methods

With ethical approval, opt-out serum screening was piloted from March 2014 to January 2015. Patients who underwent venepuncture in ED were offered an additional panel viral screen of HIV, HBV and HCV testing. An extensive staff education programme was conducted before the study commenced. Visual and verbal reminders were instituted at daily staff handovers. The study organisers provided regular study updates.

Results

Of 10,000 samples, 8839 were analysed following removal of duplicates. A sustained uptake of >50% of samples was attained by Week 3.

97, 44 and 447 patients tested positive for HIV, HBV and HCV respectively. Of these, 7, 20 and 58 were new diagnoses of HIV, HBV and HCV respectively. The incidence and prevalence of all three viruses are outlined below

HIV- incidence 0.8 per 1000, prevalence 11 per 1000

HBV- incidence 2.26 per 1000, prevalence 5.05 per 1000

HCV- incidence 6.5 per 1000, prevalence 50.5 per 1000

Conclusions

The results demonstrate a high prevalence of blood borne viruses in our population. Opt-out serum screening for blood borne viruses is feasible and acceptable in a busy urban ED for both staff and patients. It has now become standard of care in our Emergency Department.

Indtroduction:Stroke is the most common 4th cause of death around the world. Due to brain edema elevated ICP is a reason of clinical deterioration in stroke patients  (%33).  ONSD measurement with ultrasonography is an indirect and non invasive technique to detect EICP.

Aim:The aim of this study is to invastigate the diagnostic value of ONSD measurements in EICP in stroke patients.

Methods:The paper involves data concerning a control group 50 individuals with study group of 105 patients diagnosed with acute stroke at the Adult Emergency Department of Hacettepe University between February 1,2015 and June 30,2015.  Symptoms and physical examinations of the patients were recorded. We performed ON-US to all patients and ONSD measurements by US were compared with the results of study group MRI-ONSD measurements. 

Results:MRI-ONSD measurements were used to diagnose EICP and the cut off for EICP was 5.0 mm in MRI-ONSD. The study group divided in two subgroups as EICP (n=47) and non-EICP (n=58) groups. Of the 155 patients studied, 81 (%52,3) were male and 74 were (%47,6) female. The means of ONSD by US; for non-EICP group for right and left eye were 4,52 mm/4,58 mm, for EICP group were 5,01 mm/5,03 mm. The means of MRI-ONSD for EICP group were 5,05 mm/5,06 mm and non EICP group were 4,56 mm/4,61 mm. Greater than 5,0 mm ONSD by US predicted EICP with sensitivity %95,7; specificity %100, general truth value %91,4 and kappa %82,8. The means of ONSD by US were significantly correlated with MRI-ONSD measurements. Symptoms such as headache, confusion and vomiting were significantly higher in EICP group and these symptoms predicted EICP with sensitivity %95,7; specificity 87,9. The intensive care requirement was increased in EICP group rather than non-EICP group (%25,5/%6,9).  Especially MCA infarction associated with brain edema (%65,7) and elevated mortality rate (%14,3). 5 patients (%4,76) were exitus in intensive care unit and all the patients had MCA infarction.

Conclusion:As a result, ONSD measurements by US is sufficient, reliable and practical in the diagnosis of acute stroke. ICP assessment with ON-US in acute stroke patients could be used to predict treatment process, prognosis and mortality.

Introduction: Distal radius fracture is the most common fracture of the wrist. Adequacy of reduction is evaluated through two-way post-reduction graphies. In the event that inadequate reduction is ascertained in the wake of the evaluated graphies, sedation and reduction procedures are performed on the patient once again. Ultrasonography (USG) can be used in the management of the patients with distal radius fractures, however, there are no adequate number of studies suggesting the efficiency of USG alone in showing the status of reduction success. The aim of the study is to evaluate the efficiency of the use of bedside USG for determining reduction success distal radius fractures and  to investigate the detecttability of the possible causes leading to unsuccessful reduction when using USG. 

Methods: Consecutive patients applied to the emergency department of the Faculty of Medicine of Ege University between the period, April 2013–September 2013, were incorporated into this prospective double-blind cross-sectional study. The patients aged over 18, who had wrist trauma and distal radius fracture and on whom reduction was performed were included to the study. Pre- and postreduction ultrasonographic images were recorded by a research asistant trained in extremity ultrasonography, images were recorded in longitudinal and horizontal axes. 

Separately, emergency medicine specialist (EMS)also, by examining the ultrasonographic images, evaluated the angulation of the distal fragment towards the dorsal or volar part, and whether or not there was any shortening in the radius, and whether there were any multiple fragments in the dorsal part of the distal fragment. The post-reduction graphies were re-evaluated in terms of reduction success by another orthopedic surgeon uninformed about the performed procedures. The orthopedic surgeon evaluated the reduction success and, the radial height: ≥5mm, radial angulation: between 15⁰-25⁰ , and the volar tilt angle: between  0⁰-20⁰  were considered as normal values. Evaluation of orthopedic surgeon was accepted as gold standart and compared with EMS. Sensitivity, specificity, and positive and negative predictive values were measured.  

Results: Ulltrasonography was 97,5% sensitive and 95% specific in determining the reduction success, the positive predictive value (PPV) was found as 97,5%, whereas the negative predictive value (NPV) was found as 95%. When direct graphy was accepted to be the golden standard, the direction of the distal fragment was determined with 100% sensitivity and 100% specificity through ultrasonography (PPV:100%, NPV:100%). The number of the multiple fragments was determined with 86% sensitivity and 73% specificity with use of ultrasonography (PPV: 84%, NPV: 77%), while the presence of radial shortening was ascertained with 67% sensitivity and 65% specificity (PPV: 79%, NPV: 50%).

Both ultrasonography and direct graphy was determined that distal fragment located towards the volar and presence of multiple distal fragments had negatively affected the reduction success significantly. However ultrasonography was failed to determine reduction success in the presence radial shortening (p=0,582)  when direct graphy succesfully determined the reduction success (p=0.008). 

Conclusion: Ultrasonography can be helpful in determining the reduction success for distal radius fractures which needs reduction. In the future, using ultrasonography may boost reduction success prominently in the ED.

Background – 2016 has seen the publication of new definitions for sepsis and further evaluation of the SOFA sepsis scoring system. With little involvement from Emergency Department (ED) physicians, the problem now is applying them to the first few hours of patient care. The ED requires a system that sits between the blunt triage tool of 'quick SOFA' (qSOFA) and the intensive-care based and considerably more detailed SOFA Sepsis score.  The key area of difficulty with applying the SOFA score is that it relies on changes from patient’s baseline. This baseline information, however, is rarely available in its entirely in the critical period of the patient’s initial care in the ED. Assuming a baseline score of 0 for all patients will clearly result in overdiagnosis of sepsis in the ED.

Aims

• to illustrate the difficulties in applying the SOFA score within a representative ED population in comparison to the qSOFA and National Early Warning Score (NEWS)
• to develop and test an adapted SOFA score (EDdeltaSOFA) with specific, pragmatic assumptions for the ED relating to existing physiological baseline and pre-existing disease.

Methods

A retrospective analysis was performed of one month’s patients notes who had been coded for ‘infection’ within an ED database. The NEWS and qSOFA score were calculated from recorded vital signs at triage. These scores were then applied against the SOFA score (calculated from blood tests and physiological parameters within the ED) necessarily assuming a baseline as 0 and then against an adapted score.

This adapted SOFA score, the 'EDdeltaSOFA' utilises all the same categories as the SOFA score but allows for a few pragmatic assumptions based on prior knowledge or reasoned clinical suspicion of the patient’s baseline physiology. For example, for renal impairment, where previous creatinine is not known but the patient has a history of chronic renal impairment, it seems reasonable to assume a baseline SOFA score of 1 rather than a baseline score of 0.

Results

Within the sample of 169 patients who met criteria, 34 patients were excluded with missing data. 57 patients were positive for SOFA sepsis within the sample with only 42 meeting criteria with the adapted EDqSOFA score. NEWS and qSOFA performed poorly for predicting SOFA sepsis when the patient’s baseline physiology score was assumed to be zero. NEWS sensitivity 54% (C.I.s 41-67) specificity 43% (C.I.s 31-54) and qSOFA 55% (C.I.s 42-68) specificity 66% (C.I.s 54-76). They performed better when the EDqSOFA score was applied. NEWS sensitivity 88% (C.I.s 74-96) specificity 49% (C.I.s 39-59) and qSOFA 71% (C.I.s 55-84%) specificity 69% (C.I.s 58-78%)

Conclusion:

The new definitions of 2016 are an extremely welcome step forward in our understanding of the elusive clinical entity of sepsis. It is now the role of Emergency Physicians to apply the knowledge to our clinical environment. The data presented above suggests that there is a promising method of adapting the SOFA sepsis score. It is the authors’ intention to develop this tool further and conduct a series of larger validation trials for its use.

Background

NICE guidelines (NICE CG98) launched in May 2010 on neonatal jaundice mandate quantitative bilirubin testing in every neonate noticed to be visibly jaundiced. The guidelines were implemented locally in August 2011, and consequently, caused a significant surge in the number of attendances to our paediatric emergency department (ED) for bilirubin level assessments, straining emergency services significantly, as seen in a review done in 2012. Transcutaneous bilirubinometers were purchased for local midwifery teams to enable quantitative bilirubin testing in the community. This study was undertaken to review the impact of the NICE guidelines and the provision of trancutaneous bilirubinometers since.

Materials

Review of hospital episode statistics from November 2014 to August 2015 as recorded on EPIC and comparison of ED attendances against the local birth rates and inpatient admissions with neonatal jaundice as a diagnosis; and comparing this against a similar review of the data undertaken in 2012. Review of the proportion of admissions and bed days for feeding and observation compared to phototherapy and septic screens.

Results

From the previous review done in 2012 in the department, pre-guideline implementation saw an average of 14.5 patients per month present to the paediatric ED with jaundice, rising dramatically to an average of 49 patients per month post-guideline implementation. Local birth rates remained stable at about 490 births per month. Over the same time period, admission of neonates to a paediatric inpatient ward with jaundice did not rise significantly at approximately 15 admissions per month. Over the period of November 2014 to August 2015, with the introduction of transcutaneous bilirubinometers for community midwives, which allows for quantitative assessment of bilirubin levels in the community, the attendance of patients to the paediatric ED with jaundice has fallen back to baseline of an average of 13.5 patients per month (Fig. 1). This is assuming that the local birth rate remained stable. Of these attendances, 15.5% were recalls to ED for serial serum bilirubin readings. Of these recalls, 25% were recalled for two serial bilirubin tests, while the other 75% were recalled once. Of these patients, most of them had an initial presentation of jaundice alone with no other worrying features (e.g. lethargy, fever, loss of weight). All these patients were discharged with no further follow-up.

Conclusion

Before the implementation of national guidelines, a careful assessment and anticipation of its downstream effects is required. Simple investigations made available in the community will help mitigate attendances to the emergency department, and will help reduce healthcare costs and inconvenience to patients and families. Similarly, providing, encouraging or enabling utilisation of services in the community that prevent the initial problem will help in reducing attendances at the ED and admissions for observations and support services that are already available in the community. 

Introduction

It is well recognised that the job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.

Objectives

This study attempted to answer the following questions:

• In a day how many unscheduled interactions does the senior EM physician deal with?

• How many of these are interactions are clinical interactions?

• What is the average length of time spent dealing with these unscheduled interactions?

Methods

This prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was trailed on shift by a medical student who noted down all the non-patient interactions that the consultant had. The consultant had no input into data collection. The nature of the UI, the time spent and the outcome was recorded on a simple data collection form. This was then collated and analysed.

 Results

• A total of 23 shifts over 135hrs 34min were observed.

• There was a mix of early (0800-1600), late (1600-2100) and weekend shifts.

• All 10 members of the consultant body were followed.  

Total Number of UI in study period:  2082

Average Number of UI per hr:  17.95 UI/hr.

UI rate (time per UI) 3min 21seconds

Average time per UI 87.5sec   (Range 10s–34 mins)

Clinical Interaction vs Non Clinical Interactions: 94% vs 6%

Conclusion

In this single centre study of an urban UK emergency department 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 seconds

Discussion

The nature of modern EM necessitates a senior EM physician running a shift on order to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load  is not feasible and departments should consider the initiation of a ‘captain of the ship’ ‘Fat Controller’ role along with a second senior EP to provide individual consultant level care to the sickest individuals who require senior input.

Background: Volume expansion is a key component of therapy in critically ill patients, although its effect is difficult to predict using conventional measurements. Dynamic parameters, evaluated by echocardiography, have demonstrated a good diagnostic accuracy in several studies, but conflicting results have been reported. Aim of this study was to examine the feasibility and diagnostic accuracy of vena cava collapsibility index (VCCI) and velocity time integral variation after passive leg raising (PLR) in an unselected population of critically ill patients admitted to a sub-intensive clinical setting.

Methods: This is a prospective, observational, pilot study. Unselected critical patients admitted in an Emergency Department High-Dependency Unit (ED-HDU) were evaluated by transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity (AoV)  variation during PLR. According to VCCI, patients were considered fluid-responders when the value was ≥50%, non-fluid responders when the collapse was <10% and indefinite response for intermediate values. According to AoV variation after PLR, a positive hemodynamic response was defined as an increase in AoV ≥ 10%. Whenever possible, both VCCI and AoV variation during PLR were evaluated. According to echocardiographic evaluation, three therapeutic options were considered: no intervention, administration of fluids or diuretics. Any change in the therapeutic strategy by the treating physician in the following 12 hours was annotated into the clinical records.

Results: we enrolled 29 patients, mean age 75±13 years; the two most frequent reasons for ED-HDU admission were sepsis (69%) and COPD re-exacerbation (14%). VCCI was feasible in 25 (86%) patients, while PLR could be performed in 13 (45%, p=0.004). According to VCCI, 11 (38%) patients were fluid-responder, 7 (24%) were non fluid-responders and in 7 patients VCCI showed an intermediate value; PLR was concordant with VCCI in 7 patients and it gave a diagnostic result in 6 patients in whom VCCI was not feasible or not diagnostic. According to the echocardiographic evaluation, 6 patients did not receive any treatment, 16 were treated with fluids and 7 with diuretics: the therapeutic option was maintained for the following twelve hours in 23 patients, while it was modified in the remaining 6 patients. This group of patients have been evaluated only by VCCI; 3 of them were fluid-responders, 2 non fluid-responders and 1 in the intermediate group. In these patients left ventricular systolic function was slightly depressed (left ventricular ejection fraction 47±9 vs 54±17% in the remaining patients) and lactate dosage was  normal (1.3±0.7 vs 2.4±3.6 mEq/L): these differences were not statistically significant, probably in part as a consequence of the limited population size, and need to be confirmed in a larger study group.

Conclusions: VCCI appears to be very feasible in an unselected population of critically ill patients; the proportion of patients with an indefinite value, who need a further evaluation, is not negligible as well as the proportion of patients in whom the therapeutic option based on VCCI measurement had to be modified in the following hours. PLR has a limited feasibility but it shows a very good diagnostic performance.   

Introduction:

   Diabetic ketoacidosis (DKA) is one of the most commun diagnosis in the emergency department(ED). Many studies reported that DKA is the leading cause of mortality .In addition to the risk of fatality,recurrent DKA has a major impact on the quality of life of patients and many factors can be  associated with it.

Objective:

  The aim of this study was to identify the factors that influence recurrent DKA  in the ED.

Methods:

  We carried out a prospective observational cohort study in patients who were hospitalized in the ED for DKA during four years (2012-2015) .The epidemiological data ,clinical signs, etiology and  treatment were studied. An univariate linear regression analysis was carried out to find out the variables associated with recurrent DKA.

Results :

  Inclusion of 176 patients.136 with type 1 diabetes and 40 with type 2 diabetes. Mean age was 34 +/- 16 years. Sex ratio = 0,81. The major clinical signs were vomiting (69%) and dyspnea (53%). The leading precipitating causes of DKA were the poor compliance with insulin therapy (44%) and  infection (42%). A total of 145 patients presented with the first time DKA and 31 with recurrent episodes. Compared with the first-time DKA patients, those with recurrent episodes were younger (27 ±13 years vs 35 ± 16, p=0,003),had type 1 diabetes (97 % vs 78 %,p=0,008), duration of diabetes less than 5 years ( 61% vs 54 %, p=0,02 ), had more hyperventilation (Paco2= 18 ± 5 mm hg vs 22 ± 7, p=0,004),and a short delay of visit to ED (39 ± 3 hours vs 66 ± 10 , p=0,008).

Conclusion:

  The younger age , a short delay of visit ED , a low Paco2 and duration of type 1 Diabetes less than 5 years  were associated with recurrent DKA .The recognition  of such factors and the institution of specific programs might reduce DKA recurrence .

Objectives

Point of Care Ultrasound (POCUS) in emergency medicine (EM) is a goal directed analysis integrated with the clinical examination of the critically ill patient presenting to the Emergency Department (ED). Its overall scope is to provide rapid dichotomous answers to questions that arise during the assessment to rule-in or rule-out the diagnosis. In adult the integration of chest US with a bedside  ecocardiography (ECHO) improves diagnostic accuracy of acute dyspnea allowing an appropriate management of the patient. There are no data available for its impact on pediatric patient management in the ED.

 Methods

This is a prospective, single center, observational study with the aim to verify the diagnostic performance and reproducibility of  POCUS evaluation including chest, heart, and IVC in the differential diagnosis of respiratory distress in children admitted to a pediatric ED, comparing this procedure with the standard approach in use. Moreover we want to estimate the time needed to complete POCUS assessment compared to the standard approach.

The study was leaded on a sample of patients aged 29 days to 18 years with respiratory distress, for whom two clinicians performed independent evaluations. We compared the diagnosis of the first clinician assessor with the diagnosis resulted by the POCUS approach performed by the researchers. The following outcome measures were used: 1) time to the diagnosis, 2) diagnostic accuracy of the two assessments, 3) concordance of diagnosis set with the two approaches with the gold standard. We considered as gold standard the discharge diagnosis from the ED, Observation Unit or ward.

 Results

During the enrollment period 579 patients with respiratory distress were evaluated in our ED. We enrolled 68 patients so this resulted in 511 (88%) missed eligible. The sample of the patients enrolled was similar to the missed eligible by age, gender and for the presence of risk factors. There were not significant differences between the average time needed for the standard clinical evaluation and for the POCUS examination (p=0.22). The average time for POCUS examination was significantly lower than the time needed to make a diagnosis in the subset of patients that underwent chest XR (p=0.02) and significantly lower than the time needed to obtain the discharge diagnosis from the ED or Observation Unit (p<0.05). The overall agreement of the diagnostic hypotheses compared to the gold standard was moderate for both POCUS (k =0.60) and the standard assessment (k=0.54). Finally for the patients who were admitted, we calculated the agreement between the diagnosis based on the standard approach and POCUS assessment with the discharge diagnosis that resulted respectively moderate (k=0.45) and perfect (k=0.85).

In patients who presented for wheezing, POCUS assessment showed a significantly higher specificity than the clinical evaluation alone (respectively 87% 95%CI 69.2-96.2 and 43% 95% CI 25.5-62.6, p <0.05).

Conclusions

Our study showed that POCUS evaluation is useful to address a more accurate and faster diagnosis of respiratory distress in children compared to the sole standard clinical approach. In the context of pediatric emergency medicine awareness is required to apply POCUS in clinical practice

Objective: Ketorolac is a standard agent for abortive management of migraine headache in the emergency department (ED). The objective of this study was to determine if intravenous caffeine is as effective as intravenous ketorolac for the treatment of moderate to severe migraine headaches.

Methods: This randomized double blind clinical trial was conducted between January and December 2014 in two EDs in Tehran, Iran. Patients who met International Classification of Headache Disorders, 2nd edition criteria for migraine were enrolled. Based on an online random number generator, patients received 60 mg caffeine citrate or 60 mg ketorolac infused intravenously over 10 minutes. Visual analog scales (VAS) were used to measure pain at baseline and one hour and two hours after infusion. Therapeutic success was defined as improvement of 3 points on the VAS without requirement of rescue medication. A sample size calculation determined the need for at least 102 patients.

Results: 193 patients were approached for participation and 110 patients were randomized. 55 patients were assigned to each group of whom 75.5 % were women. Baseline pain scores were comparable between the groups. Therapeutic success after 60 minutes was achieved by 63.6 % of patients in the caffeine and 70.1% of patients in the ketorolac group (p=0.23). After 120 minutes, 87.3 % of the caffeine group and 83.6% of the ketorolac group achieved therapeutic success (p=0.49). Subgroup analysis did not reveal any association between age or sex and outcome.

Conclusion: In this multi-center, randomized double blind ED study, intravenous caffeine was as effective as intravenous ketorolac for first line abortive management of acute migraine.

Background:

Low back pain (LBP) constitutes a challenging health problem which causes considerable socio-economic burden to healthcare system globally. Efforts have been focused on early prognostic assessment and stratification of LBP patients to matched interventions. Recently, the STarT Back Screening Tool (SBT) for back pain prognostic indicators has been developed to help initial decision making in primary care settings and has shown clinical and economic benefits. To our knowledge, SBT has not been used in the emergency department (ED) to assess LBP patients. In this study, we aim to create a regression model by integrating SBT, demographic and clinical variables and to evaluate its predictive performance for 6-month clinical outcomes of acute LBP patients presenting to the ED of a tertiary hospital in Singapore.

Methods:

A prospective observational cohort study was conducted. Eligible patients consulting ED doctors with acute LBP were invited to participate and administered the SBT at initial evaluation. Demographic information and LBP-related clinical characteristics were either gathered from patients’ case notes or self-reported by patients via telephone interview. The primary clinical outcome was pain score measured using the Visual Analogue Scale which was collected at baseline and at 6-week and 6-month follow-up. Treatment or referral of patients was at the discretion of ED doctors in line with current best practice. Prediction of pain score at 6-month was evaluated by using a multiple regression model which integrated independent variables including SBT score, demographics (age, gender, ethnicity, BMI, employment status) and LBP-related clinical characteristics (prior LBP onset, current LBP episode duration, pain score at ED, pain score at 6-week).

Results:

A total of 173 eligible patients were recruited, of which 19 patients were excluded from the analysis due to loss of contact in 6-month follow-up. Multicollinearity diagnostic analysis showed no correlation between independent variables of interest except for SBT overall and psychosocial scores (Pearson correlation=0.90). Therefore, SBT psychosocial score was not included in the model development in this study. The multiple regression model achieved R² of 0.425 and adjusted R² of 0.375, where pain score at 6-week (β=0.58), employment status (β=-0.12) and age (β=-0.10) were the three strong predictors among all the variables.

 Conclusion:

A regression model built by integrating SBT overall score, demographic and clinical variables has shown value in predicting 6-month pain score for acute LBP patients presenting to the ED. This study concludes that a predictive model is useful in determining the pain score at 6 months and early physiotherapy should be provided to high risk patients to avoid poor outcomes.

Introduction: Although the practice of emergency medicine can be meaningful and personally fulfilling, it can also be demanding and exhausting. Emergency departments (EDs) are a particularly stressful work environment. This can be explained by difficult work conditions including significant workload and psychological demand, a default of resources, and lack of support. It is probable that these characteristics impact young emergency physicians’ perceived quality of life and work life balance. Our aim, in this study, was to evaluate quality of life and work life balance of French young emergency physicians.

Methods: We conducted a cross-sectional, anonymous, online survey of quality of life satisfaction among young emergency medicine physicians in France. The survey, containing 32 items,  was distributed by email via the AJMU network (Association of young emergency medicine physicians). Burnout symptoms were measured using validated instruments. Because other burnout studies have focused on the presence of high levels of emotional exhaustion or depersonalization as the foundation of burnout in physicians, we considered physicians with a high score on the depersonalization or emotional exhaustion as having at least 1 manifestation of professional burnout. Satisfaction level with work-life balance was explored as well. Descriptive statistics of percentage, mean and standard deviation and odds ratio calculation were used to analyse the data.

Results: 475 physicians completed the questionnaire (response rate of 33,6%). The median age was 31.5 years old (SD=2.7), among those 55.4% were women. The median duration of practice in the ED was 3.2 years. On a scale of 1 to 10, the level of satisfaction with their work was 6.6 (SD=1.8). The level of satisfaction with their life outside the ED was 7.2 (SD=2), and with their work life balance was 5.7 (SD=2.1). Overcrowding was considered stressful for 72% of responders. The mean level of perceived consideration by others specialists was 4.1 (SD=1.74). Only 7% of the physicians considered working in the ED until their retirement.  52.6% considered transferring to general medicine if they stopped working in the ED. Working more than 48 hours per week and being a woman were associated with a higher risk of presenting symptoms of burnout with a respective OR of 1.8 [1.1; 2.9] and 1.9 [1.1; 3.2].

Discussion: Our study has several strengths. The large physician sample was drawn from a young emergency physician registry, and included physicians from across our country in all type of practices, settings, and environments. However, our study is subject to several limitations among which the response rate of 33,6% among physicians who received an invitation to participate in the study is lower than expected. It is however similar to those seen in this type of questionnaire studies.

Conclusion: These results show that the young ED physicians in our study have an overall good quality of life and a satisfying work life balance. The results of a larger study would yield a greater understanding of the factors associated with work-related quality of life and burnout in the ED.

Aims: To evaluate the prognostic role of anamnestic variables and Sequential Organ Failure Assessment score (SOFA) in a population of patients admitted in an Emergency Department High Dependency Unit (ED-HDU).

Methods: ED-HDU is a clinical setting with a sub-intensive level of care, whose mission is to stabilize patients in order to prevent admission in Intensive Care Units (ICU); a maximum 48-hour ED-HDU length of stay is recommended. From June, 2014, we recorded all our patients in a standardized database; after 20 months, we analyzed the database in order to identify predictive parameters of an adverse outcome. To standardize comorbidity, Charlson index was calculated; SOFA score calculation was employed to evaluate organ dysfunction. The primary end-points were ED-HDU mortality and ICU admission.

Results: In the study period (June 2014-March 2016) we admitted 2300 patients, mean age 72±16 years (range 14-102; 5% aged ≤40 years, 22% aged 41-65 years, 38% aged 66-80 years, 34% aged >80 years), 53% male gender; Charlson index was 4±3 (range 2-15) and SOFA score was 2.4±2.6 (range 0-17). Final dispositions were: 733 patients were discharged to home, 1242 were admitted in an ordinary ward, 144 in a HDU, 138 in an ICU and 43 died.  Overall, we could stabilize and avoid a level of care increase in 86% of our patients. Compared with admitted patients, discharged patients were significantly younger  (69±16 vs 73±16 years, p<0.001) and had a lower Charlson index (3.9±2.3 vs 4.6±2.5) and SOFA score (1.0±1.3 vs 3.0±2.8 all p<0.001); 91% did not show any organ failure at admission, 89% did not have any infection (respectively vs 62% and 61% in admitted patients, p<0.001) and among the 82 patients with infection, 79 had not the criteria for sepsis or septic shock. Non-dischargeable patients were divided in three subgroups: patients admitted in ordinary ward or HDU (D1, n=1368), admitted in ICU (D2, n=138) and non-survivors (D3, n=43). D3 patients were significantly older than D1 and D2 patients (81±13 vs 73±12 and 73±16 years, both p≤0.01), had a higher Charlson index (D1: 4.5±2.5, D2 4.9±2.4, D3 6.4±2.9, p<0.001) and SOFA score (D1 2.7±2.4, D2 4.3±3.6, D3 9.8±3.8, p<0.001).  Presence of moderate to severe organ failure, involving up to two systems, increased significantly (D1 35%, D2 53% and D3 84%,  all p<0.001) in the aforementioned subgroups with increasingly worst prognosis, as well as proportion of patients with an infection at ED-HDU admission (D1 37%, D2 45%, D3 81%, p<0.001 D3 vs D1 and D2) and infection severity (sepsis/septic shock: D1 28%, D2 55%, D3 83%, all p<0.001). A multivariable regression analysis including age, Charlson index, SOFA score and presence of infection at ED-HDU admission  showed that only SOFA score showed an independent prognostic value  both for ICU admission (RR 1.21, 95%CI 1.13-1.29) and ED-HDU mortality (RR 1.76, 95%CI 1.57-1.96, all p<0.001).

Conclusions: ED-HDU carried out its own mission in the most proportion of admitted patients; a high SOFA score was the only independent predictor of a bad outcome. 

Every year, about 20 million patients in Germany visit emergency units or are transferred to emergency units by emergency services and general practitioners. The reasons why patients prefer ER as first touch point are diverse and have not been investigated systematically from the patient's perspective so far. As numerous studies have shown, a majority of patients visiting the emergency units required only outpatient emergency treatment. Moreover, the costs incurred in the ER are not covered. Apparently, the system of physician’s emergency care established in Germany is not accepted by patients as intended.

In a hospital focusing on specialized care with 36,300 emergency patients per year, a patient survey was carried out in the central emergency department to investigate the reasons why patients visit the ER and do not use the provided outpatient care structures.

Study Design:
In the Central Emergency Department, an initial assessment by MTS (Manchester Triage System) was carried out with all patients who did not have an immediate doctor contact.
The survey period lasted 4 months, the questionnaires were issued to each patient with MTS category green or blue. The survey was anonymous and participation was voluntary.

In addition to the reasons for the idea and sociodemographic data were collected on a voluntary basis. The return rate of questionnaires was 10.7%.

Results:
57.5% of respondents were older than 40 years. From all respondents of MTS categories green and blue, 40.6% rated themselves a minimum to average life-threatening emergency. 52.7% of respondents had not been previously treated by a doctor. 70.1% have presented themselves in the ER. The 3 main reasons which led the patient to visit the emergency department:
1. "I think I'm getting better care in the ER (get all necessary investigations)" - 39.4%;
2. "I think the first point is the hospital" - 19.1%;
3. "The period when domestic / Specialist by a deadline takes too long" - 17.1%.

The survey results clearly express the view of the patients and can lead to a better understanding of the reasons why ER are visited in hospitals. Despite long waiting times, particularly for patients with low treatment urgencies, patients place the hospital emergency first in 60% of the cases. The own feeling as an emergency is more pronounced in the patients, as it is expected by the triage level. The statements of the patient in the survey can be regarded a representative sample as usual sociodemographic factors of the survey (age distribution, presentation days / times / Education) reflect the usual clientele of patients in the ZNA.
Thus, the expectation of the patients should be taken care of, and the in-hospital emergency care in Germany should be strengthened. It remains open to what extent, for example, information campaigns on the supply system in Germany can lead to a reduction of the treatments of patients in emergency rooms.

For the patient, a timely and customized emergency care appears to be important. Professional societies and politics in Germany will need to take care of this.

Introduction: Pain is one of the most common complaints of patients referred to emergency department (ED) and its control is one of the most important responsibilities of the physicians. The present study was designed, aiming to compare the efficiency of intranasal sufentanil and intravenous (IV) morphine sulfate in controlling extremity trauma patients' pain in ED. Methods: In the present clinical trial, extremity trauma cases referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2014 to March 2015 were randomly divided into 2 groups treated with intranasal sufentanil (0.3 μg/kg) and IV morphine sulfate (0.1 mg/kg) single-doses. Demographic data and information regarding the quality of pain control such as pain severity before intervention and 15, 30, and 60 minutes after intervention, and probable side effects were gathered using a checklist and compared between the 2 groups. Results: 88 patients with the mean age of 35.5 ± 14.8 years were included in the study (81.8% male). 44 patients received IV morphine sulfate and 44 got intranasal sufentanil. No significant difference was detected between the 2 groups regarding baseline characteristics. In addition, there was no significant difference in the groups regarding pain relief at different studied times (p = 0.12; F = 2.46; df: 1, 86). Success rate of the drugs also did not differ significantly at different studied times (p = 0.52). No significant difference was seen between the groups regarding side effects (p = 0.24). Conclusion: Based on the results of this study, it seems that intranasal sufentanil has a similar effect to IV morphine sulfate in rapid, efficient, and non-invasive pain control in patients with traumatic extremity injuries.

Introduction – In the emergency department (ED) and pediatric department (PD), minor procedures in children are often challenging due to anxiety and lack of cooperation by the child. Nitrous oxide (N₂O) seems a suitable agent for procedural sedation (PSA). It has a rapid onset and offset, no fasting period is required and self-administration is possible. Although safety and efficacy were proven in international literature, PSA with inhaled N₂O is only minimally used in Dutch hospitals. In this study we describe the implementation of procedural sedation with nitrous oxide in our hospital in a two year cohort.

 Methods –  All patients that underwent procedural sedation (PSA) with N₂O (50%) in the emergency and pediatric department were retrospectively identified. Data on patient characteristics, type of procedure, depth of sedation and adverse events were recorded. PSA was performed using standardized pre-sedation assessment, monitoring during procedure and post-sedation discharge criteria. Concomitant use of systemic analgesia was contra-indicated. All medical staff was trained according to protocol, this included theoretical background training and supervision during the first five procedures. Knowledge of advanced life support was required. PSA could be executed by a well-trained nurse without supervision of a doctor. 

Results – During 2014 and 2015, 202 patients received PSA with inhaled N₂0, 48 patients were excluded due to missing data. 154 patients were included in this study. These were 86 boys and 68 girls with a mean age of 6,6 years (SD 3.9 years). Sedation was successful in children from the age of two years old. Procedures in which sedation was used; wound care (N=106), venous access (N=25), reduction of fracture (N=15), lumbar puncture (N=4), the administration of a plaster cast (N=2) and placement of a urine catheter (N=2).

97,4 percent of children had an ASA classification score of one. Mean duration of procedure was 17 minutes (SD 9,8 minutes).

Most reported side effect was laughing (N=57).There were no reported major adverse events. There were 16 reported cases in which comfort and suppression of anxiety during PSA were inadequate and the patient was uncomfortable during the procedure. There were seven reported cases in which the procedure could not be successfully completed. One procedure had to be aborted due to malfunction of  equipment. The other six procedures included; stitching of wounds to the face (N=3), placement of a urine catheter (N=2) and reduction of an incarcerated inguinal hernia (N=1). These procedures are known to be unpleasant and painful, especially in young children.

Conclusion– Sedation with nitrous oxide is safe, feasible and effective for both patient and medical staff in minor procedures in the emergency and pediatric department. In the vast majority (96.1%), sedation was successful. In more painful procedures, sedation without concomitant analgesia proved to be inadequate (N=6) and procedures could not be completed. For this reason the use of concomitant systemic analgesia with opiates was included in our protocol in 2016. Implementation of procedural sedation with N₂O requires adequate training of medical staff and a close collaboration between the emergency and pediatric department.

Introduction: In Canada, trauma injuries represent almost 200,000 hospital admissions per year. Depending on the type of trauma and other risk factors, a good proportion of patients will eventually develop mild to severe chronic pain. Fortunately, the early use of some treatments appears promising to prevent chronicity of post-traumatic acute pain. However, the research allowing the early identification of the subpopulation of trauma patients that may develop chronic pain is scarce and limits our capacity to test these preventive approaches.

Objective: To identify factors available at hospital admission associated with the development of chronic pain in a population of trauma patients.

Methods: In a cohort study performed on a registry of prospectively acquired data, we have included all patients 18 years and older admitted for injury in any of the 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Patients who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma were compared to patients who did not meet those criteria. Patients with a follow-up period lesser than 1-year and those with multiple trauma episodes were excluded.

Results: A total of 90 479 patients were retained. Mean age was 59.3 (±21.7), 53% were men, and the mean follow-up was 4.8 years (±2.4). The major causes of trauma were: falls (63%), motor vehicle accident (22%), as well as penetrating and blunt injuries (9%). We have identified 6172 patients (6.8%; 95CI:6.6%-7.0%) who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma. After controlling for confounding factors, the variables that were associated with the development of chronic pain were: spine injury (OR=2.3; 95CI: 2.1-2.4), loss of consciousness (OR=1.7; 95CI: 1.5-2.0), nerves damage (OR=1.7; 95CI: 1.5-2.0), history of depression (OR=1.5; 95CI: 1.3-1.6), history of alcoholism (OR=1.4; 95CI: 1.2-1.7),  head injury (OR=0.62; 95CI: 0.56-0.68), multiple trauma (OR=1.4; 95CI: 1.3-1.5), and being a female (OR=1.2; 95CI: 1.1-1.3). Receiving operating characteristic curves derives from the model was evaluated at 0.70.

Conclusions: Despite low incidence of chronic pain development found in our trauma cohort registry, several significant risk factors were identified. Hospital admission screening of the trauma population at risk of developing chronic pain will allow the early testing of preventive approaches.

Introduction: Emergency Departments (ED) are the front line of public health care system and are often confronted to end-of-life care. These situations are difficult and uncomfortable for patients, families as for medical staff. Leonetti law (2005) strengthened by Clayes Leonetti law (2016) forbids “unreasonable obstinacy” and frames decisions concerning means limitation or ending active therapeutic means. In this recent context, we wanted to assess professional practices concerning the decision making and medical management of end-of-life situations.

Material: We conducted a retrospective monocentric study from october 2015 to april 2016 in an ED of an academic hospital. Through medical charts, we included all patients that died in the ED or in the emergency hospitalization unit through the period and for whom a means' limitation decision had been taken.

Results: n=53 patients presented the inclusion criteria (0,1% of all visits). For 57% of these patients, the limitation decision wasn’t clearly written in the chart. 30% of these decisions were taken by a sole practitioner. In the first moments of their arrival in the ED, 28% of these patients had invasive yet inappropriate care. 55% of these patients were visiting the ED for the first time. 21% died in the first 4 hours after being admitted to the ED. We noticed wide heterogeneous pratices while managing dyspnea, pain, consciousness and sedation.

Conclusion: End-of-life situations are part of ED care. However care limitations are difficult decisions and are not easily and efficiently managed. Education is necessary for medical and paramedical staff in order to help those patients through these moments.

Background

NICE CG 89 ‘Child maltreatment: when to suspect child maltreatment in under 16s’ ⁽¹⁾ suggests that health professionals should consider safeguarding issues in all encounters with children, gives guidance on when to suspect abuse, and stresses the importance of documentation. The Emergency Department is a place where this is of particular importance as children often present with injuries that could be indicative of maltreatment, such as burns or head injuries. Therefore, all attendances should have a record of a safeguarding assessment stating whether the possibility of child abuse has been considered or suspected. Previous audits ⁽²⁾ have shown that the level of documentation of safeguarding assessments in the ED was very high, with an excess of 90% of children having safeguarding considerations documented. This level was achieved following the implementation of a written prompt in the paper based patient record. Since the last audit in 2013 the hospital has introduced a new electronic system of patient records, Epic. This re-audit aims to assess whether the high levels of documentation have been maintained after the implementation of this new system the safeguarding section of which will be briefly presented.

Methods

Electronic patient records of all Paediatric ED attendances during the week 01/02/16 to 08/02/16 were reviewed and checked as to whether clinical staff completed the required documentation of safeguarding assessments and to gather information about those with absent safeguarding assessments. Sample size: 414. Results wre compared to the previous audit performed in 2013.

Results

385 (92.1%) had a safeguarding assessment completed, in 29 (7.9%) cases the assessment was missing. Re-attenders (n=14) had no safeguarding assessment documented on the second attendance in 6 cases. Split into age groups, the percentage of assessments not completed ranged from 8.33% in the 6 - 10 year olds to 5% in the 1 - 5 year olds. 15 patients (3.6%) in whom safeguarding assessments were missing presented with diagnoses like burns, head or other injury.

Conclusion

Following the implementation of a new electronic system of patient record keeping and thus the removal of the previous ED paper based system with its well established prompts, documentation of presence (or absence) of safeguarding concerns in the Paediatric Emergency Department remains in excess of 90%. This is despite the fact that safeguarding assessments on Epic are not a compulsory documentation item, reflecting a positive culture of safeguarding awareness. Children who re-attended the ED were amongst those who were lacking safeguarding assessments when attending the second time but one coud argue that this may be appropriate in the vast majority of patients that re-attend within such a short time.  The current system is effective but still does not capture a proportion of patients that present with significant injuries.

Introduction:

German immigration laws require refugees to undergo medical screening as part of the asylum application process. This consists of a self-reporting questionnaire, a physical examination and a tuberculosis screening. There appears to be some anxiety whether refugees pose a public health threat to the German population through higher than usual rates of communicable diseases. This study aims to assess the incidence of communicable diseases, i.e. head lice, scabies, hepatitis, HIV or tuberculosis amongst refugees.

Methods:

We collected data on communicable diseases of refugees living in holding camps in the County of Lippe, Germany. All refugees not having undergone a medical screening examination or parts thereof underwent a medical screening examination as part of the weekly refugee medicine clinics run by the emergency department. Demographical data including age, gender and country/region of origin as well as any notable findings during the self-reporting questionnaire, physical examination and tuberculosis screening were recorded. Tuberculosis screening consisted of either chest radiographs, interferon-gamma immuno-assay or a Mendel-Mantoux skin prick-test, or a combination of these, depending on age and/or pregnancy status.

Results:

The County of Lippe operates 6 refugee camps with a capacity of 70-700 refugees each. From October 2014 until March 2016 altogether 9,992 refugees were registered for medical examination with 8,678 actually attending (86.8%). Of these, 69.3% were male and 30.7% female. The mean age was 24 years. Most refugees originated from Western Asia (41.8%), followed by those coming from Balkan states (21.7%), Africa (8.3%) and former Soviet states (6.9%).

As part of tuberculosis screening 3,327 refugees underwent chest x-ray in our clinic, whereas 3,096 were x-rayed elsewhere. 1,192 refugees received interferon-gamma immuno-assay and 769 children under the age of 6 years received a Mendel-Mantoux skin prick-test. Due to a lack of supply of Mendel-Mantoux serum from December 2015 onwards in whole Europe, 123 children did not receive any tuberculosis screening at all.

Overall, only 66 refugees were found to have scabies (0.76%) and 49 (0.56%) were tested positive for head-lice (0.56%). In contrast, 676 refugees had a non-communicable yet relevant medical condition (7.78%) requiring follow-up. We found 50 of 8,524 screened refugees to have an abnormal tuberculosis screening result (0.59%). Of these, only 7 were confirmed to have active tuberculosis requiring standard combination therapy (0.08%) and 3 refugees required isolation due to open tuberculosis (0.04%). Interestingly 27 refugees were known to suffer from viral hepatitis (0.31%) and 7 reported to be HIV-positive (0.08%).

Discussion:

This study is the first to describe the incidence of notifiable/communicable diseases and tuberculosis amongst a representative sample of refugees coming to Germany. Although only 0.8% of the total refugees entering Germany were included, the results appear to be fairly comparable to the overall refugee population. The incidence of tuberculosis amongst refugees appears to be 11 times higher than for the resident German population. Nevertheless, the projected overall number of approximately 500 new tuberculosis cases amongst refugees compared to an overall national incidence of 5,895 new cases in 2015 does not seem to pose any serious public health threat.

Importance: Fever is one of the most common symptoms in children. It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). 

Objectives: To systematically review and to perform a meta-analysis, in order to determine whether children suffering from high fever are at high risk for SBI.

Data sources: The following databases were searched from their inception until the last week of December 2014: Embase (via Embase.com), Medline (via OvidSP) and Pubmed.

Study selection: Cohort and case control studies comparing the incidence of SBI in children with a temperature higher than 41⁰C,  with children with fever of 41⁰C or less, and children with a temperature higher than 40⁰C, with children with fever of 40⁰C or less.

Data extraction and synthesis: Based on a preliminary review, two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted based on age.

Main outcome and measures: SBI

Results: Ten studies met the inclusion criteria.  Only two studies compared children with temperature over 41⁰C with children with lesser degree of fever. Children with temperature over 41⁰C had higher risk for SBI (OR 1.96 95%CI 1.3-1.97). Nine studies reported on children with temperature over 40⁰C. The summary end-point suggests an increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67;6.22). When analyzing the studies reporting on young infants, the odds ratio for SBI in children with temperature over 40⁰C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44;8.95). Four studies reported on older children; the odds ratio for SBI in children with high fever was only slightly higher than in children with lower degree of fever (OR 1.36 95% CI 1.16;1.61).

Conclusions and relevance: Young infants with temperature higher than 40⁰C are at increased risk for SBI. Compared with children who have lower degree of fever, the risk of SBI in older children with temperature >40⁰C is minimal.

Introduction
The influence of gender on health and disease is increasingly being recognized. In emergency medicine, sex-specific differences are well described in adults, including the acute presentation of certain conditions, the epidemiology of illnesses and injuries, and the effects and side-effects of medications. Beside physiologic and biologic factors, gender-specific biases are found to influence physician’s treatment decisions. So far, little is known about how gender affects emergency care for children. The aim of this study was to assess the role of gender in presenting problem, disease management and outcome in children attending the emergency department(ED).

Methods
This study is part of the TrIAGE project, a prospective observational study in five ED’s in four European countries (the Netherlands, United Kingdom, Austria, Portugal). Data collection consists of routinely recorded patient data, automatically extracted from electronic medical records. Study sites are instructed in data collection and a minimum set of required variables. Data harmonization and quality checks were performed.  We included all consecutive children aged

Results
In total, 84,747 children under the age of 16 were included in the study, and 54.2% were male. In all 5 hospitals, the proportion of boys visiting the ED was higher than girls, ranging from 52.0 to 58.4%. The proportion of boys decreased with age, from 56.5% (range 52.3-61.4%) in children 12 years. Boys presented more often with trauma and limb problems (22.0% versus 19.7%), presented more often with high-urgent problems according to the Manchester Triage System (12.9% versus 10.6%) and were more often admitted (11.9% versus 10.6%). When adjusted for clinical parameters, diagnostics and therapy, and patient disposition, some differences between boys and girls remained. Girls were triaged less often with a high urgent triage category (OR 0.85, 95%CI 0.81-0.89). Moreover, in girls significantly more lab tests were performed in case of medical problems (OR 1.09, 95%CI 1.04-1.14) and more radiologic tests in case of trauma (OR 1.16, 95%CI 1.09-1.24). Girls were less likely to receive inhalation medication (OR 0.72, 95%CI 0.68-0.77), while overall there was no difference in oral or intravenous medications administered.

Conclusion
In childhood, boys attend the ED more often than girls, and this trend decreases with age. When adjusted for potential confounders, girls were triaged less often to a high urgency category. Moreover, some gender-based differences were found in diagnostics and management. Further research is needed to explore whether these findings are caused by differences in disease type, disease presentation, symptom severity or whether gender subconsciously plays a role in management decisions in children. 

Background

Vertigo and unbalance are frequent complaints in emergency department (ED), often due to a benign disease. However, the possibility of an acute brain disease is not remote and vertigo assessment is usually time and resource consuming. We aimed to investigate the diagnostic accuracy of an ED driven diagnostic algorithm.

Methods