Showing papers in "Emergency Medicine Journal in 2010"
TL;DR: A critical review of the literature pertaining to emergency department triage is provided to inform the direction for future research and to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda.
Abstract: Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.
227 citations
TL;DR: The role and structure of HEMS in a modern trauma service is a debate that is likely to continue and should be specific to critical incident frequency, geographical arrangements of hospital facilities and travel times within each trauma network.
Abstract: Background and aim Prehospital care of trauma patients is a matter of great debate. The optimal transport method remains undecided, with conflicting data comparing helicopter and ground emergency medical transfer. This study systematically reviews the evidence comparing helicopter and ground transfer of trauma patients from the scene of injury. Methods A systematic literature review of all population-based studies evaluating the impact on mortality of helicopter transfer of trauma patients from the scene of injury. We searched MEDLINE, CINAHL and EMBASE from January 1980 to December 2008 and selected and reviewed potentially relevant studies. Results A search of the literature revealed 23 eligible studies. 14 of these studies demonstrated a significant improvement in trauma patient mortality when transported by helicopter from the scene. 5 of the 23 studies were of level II evidence with the remainder being of level III evidence. Data were then entered into an evidence table and reference made to transport staffing, intubation rate, time at scene and time/distance of transfer. Conclusions The role and structure of HEMS in a modern trauma service is a debate that is likely to continue. Prehospital care design should be specific to critical incident frequency, geographical arrangements of hospital facilities and travel times within each trauma network. It is also important to consider the benefits and capabilities of the emergency medical team separately from the transport method being considered. An effective helicopter EMS will ultimately depend on effective operating procedures and tasking protocols, clinical governance, and auditing of the helicopter EMS activity.
114 citations
TL;DR: The risk factors from multivariate analysis correspond to the current understanding that coagulopathy is influenced by several clinical key factors; for example, an ongoing state of shock (at the scene and in the ED) was associated with a threefold increased risk of developing coagULopathy.
Abstract: Objective The role of acute coagulopathy after severe trauma as a major contributor to exsanguination and death has recently gained increasing appreciation, but the causes and mechanisms are not fully understood This study was conducted to assess the risk factors associated with acute traumatic coagulopathy together with quantitative estimates of their importance Methods Using the multicentre Trauma Registry of the German Society for Trauma Surgery, adult trauma patients with an Injury Severity Score ≥16 were retrospectively analysed for independent risk factors of acute traumatic coagulopathy on arrival at the emergency department (ED) by multivariate stepwise logistic regression analysis Coagulopathy was defined as prothrombin time test (Quick9s value) Results A total of 1987 patients was eligible for further analysis Independent risk factors for acute traumatic coagulopathy calculated by multivariate analysis were the Injury Severity Score, abdomen Abbreviated Injury Scale score, base excess, body temperature ≤35°C, presence of shock at the scene and/or in the ED (defined as systolic blood pressure ≤90 mm Hg), prehospital intravenous colloid:crystalloid ratio ≥1:2 and amount of prehospital intravenous fluids ≥3000 ml Conclusions The risk factors from multivariate analysis correspond to the current understanding that coagulopathy is influenced by several clinical key factors; for example, an ongoing state of shock (at the scene and in the ED) was associated with a threefold increased risk of developing coagulopathy When adjusted for all factors including the amount of prehospital intravenous fluids, a high colloid:crystalloid ratio was still associated with coagulopathy on admission to the ED The recognition, prevention and management of the mechanisms and risk factors of coagulopathy aggravating haemorrhage after trauma are critical in the treatment of the severely injured patient
105 citations
TL;DR: The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies, as well as the effect of training in healthcare professionals.
Abstract: Objective In the case of an emergency, fast and structured patient management is crucial for a patient9s outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students9 abilities to manage emergency situations. Methods A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention. Results The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p Conclusions The simulation-based intervention offers a positively evaluated possibility to enhance students9 skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.
86 citations
TL;DR: Too many patients with acute bacterial meningitis are being sent for unnecessary CT scans, causing delays in the LP, and reducing the chances of a positive CSF culture after starting antibiotics.
Abstract: Introduction Bacterial meningitis is a medical emergency, the outcome of which is improved by prompt antibiotic treatment. For patients with suspected meningitis and no features of severe disease, the British Infection Society recommends immediate lumbar puncture (LP) before antibiotics, to maximise the chance of a positive cerebrospinal (CSF) culture. In such patients, CT scanning before LP is not needed. Methods The case notes of adults with meningitis admitted to a large district general hospital over 3 years were reviewed. Patients were classified as Likely Bacterial Meningitis or Likely Viral Meningitis based on their CSF and peripheral blood results using the Meningitest Criteria, with microbiological and virological confirmation. Results Of 92 patients studied, 24 had Likely Bacterial Meningitis, including 16 with microbiologically confirmed disease (none had PCR tests for bacteria). Sixty-eight had Likely Viral Meningitis, four of whom had viral PCR, including one with herpes simplex virus. No patient had an LP before antibiotics. CSF culture was positive for eight (73%) of the 11 patients who had an LP up to 4 h after starting antibiotics, compared with eight (11%) of 71 patients with a later LP (p<0.001). None of the 34 LPs performed more than 8 h after antibiotics was culturepositive. For 62 (67%) of the 92 patients, the delay was due to a CT scan, although only 20 of these patients had a contraindication to an immediate LP. Conclusions Too many patients with acute bacterial meningitis are being sent for unnecessary CT scans, causing delays in the LP, and reducing the chances of a positive CSF culture after starting antibiotics. However, even if antibiotics have been started, an LP within 4 h is still likely to be positive. Molecular tests for diagnosis should also be requested.
85 citations
TL;DR: Supraglottic airway devices (eg, laryngeal mask airway), which were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative prehospital airway device for paramedics.
Abstract: Paramedic tracheal intubation has been practised in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcomes. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate, and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (eg, laryngeal mask airway), which were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative prehospital airway device for paramedics.
74 citations
TL;DR: VAS and VNRS are not interchangeable in assessing an individual patient's pain over time in the emergency department (ED) setting and V NRS has practical advantages over VAS in this setting.
Abstract: Objectives To compare the Visual Analogue Scale (VAS) and the Verbal Numerical Rating Scale (VNRS), in the assessment of acute pain in the emergency department (ED). Furthermore, to determine the influence of demographics on this agreement and practical limitations of the scales. Setting St Vincent9s University Hospital, Dublin; a 479-bed teaching hospital; annual ED census 36 000 adult patients. Methods A prospective observational study was conducted on ED patients with acute pain as a component of their presenting complaint. Eligible patients scored their pain on both VAS and VNRS within 1 hour of arrival. They rescored their pain every 30 minutes for 2 hours using both scales. The primary outcome measure was agreement between VAS and VNRS. Secondary outcomes were ease of pain scale use and effect of patient demographics on pain scores. Agreement between scores was evaluated using the Bland-Altman method. Results 123 patients were included (median age 35; 43.9% male). There was a strong correlation between VAS and VNRS (r s =0.93). However, there was not perfect agreement between the two scales. Patient age (older age, p Conclusions VAS and VNRS are not interchangeable in assessing an individual patient9s pain over time in the ED setting. VNRS has practical advantages over VAS in this setting.
72 citations
TL;DR: Overall an increase in hospital resources, as measured by the number of nurses, doctors and physical beds, is associated with a significant reduction in patient care time in the ED.
Abstract: Objective To quantify the determinants of the duration of time spent in an emergency department (ED) for patients who need admission to hospital. Methods A retrospective analysis of a year of administrative data on all patients presenting to 38 public hospital EDs in Victoria, Australia in 2005/2006. Individual administrative data on patient care time, defined as the time in the ED from first being seen by a treating doctor to admission, were analysed using parametric survival analysis (generalised γ model). Patient times were regarded as censored if the patients died in the ED or were transferred to another hospital. The outcome measure was the elasticity of patient care time, calculated as the percentage change in time for a 1% change in continuous variables and a unit change in dichotomous variables. Results The mean patient care time was 396 min (95% CI 395 to 398). Reduced time in ED was associated with the number of nurses (elasticity=−2.38%; 95% CI −2.31 to −2.45); the number of beds (elasticity= −2.99%; 95% CI, −2.89 to −3.08); the number of doctors (elasticity=−0.235%; 95% CI −0.232 to −0.237). There was significant variation in the time spent in the ED across hospitals after adjustment for observable differences in patient and hospital characteristics. Overall an increase in hospital resources, as measured by the number of nurses, doctors and physical beds, is associated with a significant reduction in patient care time in the ED. Conclusion Increasing hospital capacity is likely to reduce overcrowding in the average ED, but factors that determine congestion in individual hospitals need to be further investigated.
71 citations
TL;DR: Reported management of early sepsis varies between specialities and countries, and the responses do not follow SSC guidelines.
Abstract: Objective A study was undertaken to characterise how doctors in emergency medicine (EM), acute medicine (AM) and critical care (ICU) in the UK, USA and Australia and New Zealand (ANZ) approach the initial resuscitative care of patients with severe sepsis. Methods In 2007, members on the mailing lists of UK, US and ANZ EM, ICU and AM specialist organisations were invited to answer an anonymous scenario-based online survey. Respondents described their management of a patient with pneumonia and signs of sepsis. Multiple-choice questions were based on the Surviving Sepsis Campaign (SSC) 6-hour resuscitation bundle guidelines while avoiding the specific terms “sepsis” and “SSC guidelines”. Results The response rate was 21% (2461/11 795). Only two respondents (0.1%) complied with all SSC resuscitation recommendations. Inter-specialty and inter-country variations included differences in reporting initial lactate measurement (ranging from 30% in US-EM to 79% in UK-EM), fluid resuscitation targeting a central venous pressure of 8–12 mm Hg (from 15% in ANZ-ICU to 60% in UK-EM), blood transfusion for a central venous oxygen saturation Conclusions Reported management of early sepsis varies between specialities and countries, and the responses do not follow SSC guidelines. Concerns relate to knowledge, attitudes and resources.
70 citations
TL;DR: The FFC is a more realistic and preferred model for direct laryngoscopic orotracheal intubation training and Trucorp and Laerdal manikin can be used as alternative models.
Abstract: Objective: To compare the acceptability and preference between manikin models and fresh frozen cadaver (FFC) for direct laryngoscopic orotracheal intubation training. Methods: In this prospective crossover trial, participants in the airway workshop performed direct laryngoscopic orotracheal intubation on four airway training manikins: Airway Management Trainer (Ambu, St Ives, UK), Airway Trainer (Laerdal, Medical, Stavanger, Norway), Airsim (Trucorp, Belfast, Northern Ireland) and “Bill 1” (VBM, Sulz, Germany), and FFC. Participants were asked to access the following: reality of jaw mobility, difficulty with mouth opening, reality of neck flexibility, difficulty with intubation, overall model reality and model preference for each model using a visual analogue scale (VAS) of 0–10 cm. The VAS scores for each model were compared. Results: Fifty-six participants were included in the study. The FFC had a highest VAS score for reality of jaw mobility, overall reality and preference of model. Trucorp manikin and Laerdal manikin followed cadaver. There were no significant statistical differences between Trucorp manikin and Laerdal manikin. In difficulty with mouth opening and difficulty with intubation, Trucorp manikin had the lowest VAS score. Conclusion: The FFC is a more realistic and preferred model for direct laryngoscopic orotracheal intubation training. Trucorp and Laerdal manikin can be used as alternative models.
69 citations
TL;DR: The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established and the use of tracheal intubation as a routine intervention should be reconsidered.
Abstract: Introduction The most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients. Methods A 4-year, observational, retrospective case review. Patients attending the Emergency Department of the Royal Infirmary of Edinburgh, Scotland, with a primary diagnosis of OHCA were identified. Patient demographics, survival to admission, airway management technique and complication rates were identified. Results Seven hundred and ninety-four cases were identified. The aetiology of cardiac arrest was medical in 95.2%, traumatic in 3.9% and unrecorded in 0.9%. Prehospital intubation was attempted in 628 patients. Prehospital intubation was successful in 573 patients. A significant complication (multiple attempts, displaced endotracheal tube or oesophageal intubation) occurred in 55 (8.8%) patients. 165 (20.8%) patients survived to hospital admission, of whom 110 had undergone prehospital intubation. 55 patients who did not undergo prehospital tracheal intubation survived to hospital admission. Conclusion The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established. Prehospital tracheal intubation for OHCA is associated with significant complications and may reduce survival. The use of tracheal intubation as a routine intervention should be reconsidered. Ambulance services should consider adopting alternative strategies in airway management.
TL;DR: Most dizzy patients had benign causes and several clinical factors favoured a diagnosis of central neurological causes of dizziness, including Hypertension and diabetes mellitus.
Abstract: Objectives Dizziness is a common presenting complaint in the emergency department (ED). This prospective study describes the incidence, causes and outcome of ED patients presenting with dizziness and tries to identify predictors of central neurological causes of dizziness.
Methods Single-centre prospective observational study in a university teaching hospital ED in Hong Kong. All ED patients (≥18 years old) presenting with dizziness were recruited for 1 month. Symptoms, previous health, physical findings, diagnosis and disposition were recorded. The outcome at 3 months was evaluated using hospital records and telephone interviews. Follow-up was also performed at 55 months using computerised hospital records to identify patients with subsequent stroke and those who had died.
Results 413 adults (65% female, mean 57 years) were recruited. The incidence of dizziness was 3.6% (413/11 319). Nausea and/or vomiting (46%) and headache (20%) were the commonest associated findings. Hypertension (33%) was the commonest previous illness. Central neurological causes of dizziness were found in 6% (23/413) of patients. Age ≥65 years (OR=6.13, 95% CI 1.97 to 19.09), ataxia symptoms (OR=11.39, 95% CI 2.404 to 53.95), focal neurological symptoms (OR=11.78, 95% CI 1.61 to 86.29), and history of previous stroke (OR=3.89, 95% CI 1.12 to 13.46) and diabetes mellitus (OR=3.57, 95% CI 1.04 to 12.28) predicted central causes of dizziness.
Conclusions Most dizzy patients had benign causes. Several clinical factors favoured a diagnosis of central neurological causes of dizziness.
TL;DR: Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flow.
Abstract: Introduction The delivery of high quality emergency medicine ideally involves input from senior doctors 24 h a day This study aims to assess the influence of ‘real-time’ senior clinician supervision on patient disposition from a UK emergency department Methods The study was set in a UK teaching hospital with 24 h senior cover Patients were initially seen by a junior doctor who completed a plan for the patient before seeking senior advice Primary outcome measures were a change in patient outcome of discharge, admit, telephone speciality for opinion or outpatient follow-up Results 556 patients underwent senior review during the study period Review reduced inpatient admissions by 119% (95% CI 72% to 182%) and specifically reduced admissions to the acute medical assessment unit by 212% (95% CI 135% to 308%) Inappropriate discharge was prevented in 94% (95% CI 62% to 137%) and appropriate use of outpatient facilities resulted in a rise of 346% in appointments Conclusions Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flow
TL;DR: The scores of accuracy ratings for triage nurses can be improved if factors contributing to inaccuracy can be altered, and the findings of this study can be used to guide improvements.
Abstract: Objectives To gain an understanding of the accuracy of acuity assessment made by emergency department (ED) triage nurses, to compare the differences between the characteristics of triage nurses according to hospital variables and the accuracy of acuity ratings, and to explore the influence of nursing variables on the judgement of triages. Methods A cross-sectional questionnaire survey was conducted at the EDs of hospitals in northern Taiwan. Ten adult emergency case scenarios and a demographic sheet with high validity were developed to survey 279 triage nurses. Data were collected from April to October 2006. All data were analysed using percentage, mean, SD, independent t test, one-way ANOVA and a stepwise logistic regression analysis. Results The average score of rating accuracy was 5.62 points (out of a possible total of 10 points), which was considered low. Approximately 24.3% (n=68) of nurses9 triage ratings were under-triaged and 19.7% (n=55) were over-triaged. Factors included years of ED experience, hours of triage education, level of hospital and triage mode of delivery. These factors were identified as significantly affecting the accuracy of nurses9 judgement (p Conclusion The scores of accuracy ratings for triage nurses can be improved if factors contributing to inaccuracy can be altered. The findings of this study can be used to guide improvements.
TL;DR: The ease and speed at which a supraglottic airway can be inserted means that it is a viable alternative to the use of the BVMV and can be effectively used by non-anaesthetists.
Abstract: Background Control of the airway is a priority during cardiopulmonary resuscitation and/or following a failed intubation attempt. Supraglottic airway devices provide more effective airway management than bag-valve-mask-ventilation (BVMV) and can be effectively used by non-anaesthetists. Methods 36 paramedic students were timed to ascertain how long it took them to place an Igel, laryngeal mask airway (LMA) or laryngeal tube airway (LTA) into a manikin. Following insertion, students were interviewed to see which device they preferred and why. Results The Igel was consistently the fastest airway device, taking a mean of 12.3 s (95% CI 11.5 to 13.1) to insert, the LTA took a mean time of 22.4 s (95% CI 20.3 to 24.5) and the LMA 33.8 s (95% CI 30.9 to 36.7). 63% of students would choose the Igel as their preferred intermediate airway device, stating ease of use and speed of insertion as the primary reasons. Conclusion The ease and speed at which a supraglottic airway can be inserted means that it is a viable alternative to the use of the BVMV.
TL;DR: Streamlining the admission process for unscheduled patients leads to improvement in care, decreases prescribing errors and reduces either potential or actual harm.
Abstract: Aim To improve medication history accuracy and reduce prescribing errors for unscheduled patients admitted via the emergency department (ED). Design A prospective observational study of 100 adult unscheduled admissions with 50 patients in both pre and post-intervention groups. One investigator completed the required information including patient demographics, admitting speciality, number and types of any medication errors detected. In the post-intervention group, the investigator (a pharmacist independent prescriber) completed systematic medicine reconciliation in the ED before patient transfer and initiated the original inpatient prescription chart, as appropriate. Background and Setting The ED in a busy district general hospital with an emergency admission rate of 24 000 patients per annum. Key Measures for Improvement An increase in medicine reconciliation and initial prescribing within the ED with a reduction in prescribing error rates. Strategies for Improvement Change needed to be communicated to all staff involved in process: ED medical and nursing staff; appropriate clinical directors; pharmacy staff. Effects of Change Medicine reconciliation completed within 24 h of admission increased from 50% to 100% and prescription chart initiation in the ED increased from 6% to 80%. The prescribing error rate was reduced from 3.3 errors to 0.04 errors per patient (difference 95% CI 2.5 to 5.1). Lessons Learnt Streamlining the admission process for unscheduled patients leads to improvement in care, decreases prescribing errors and reduces either potential or actual harm. Moving pharmacists9 work to the ED better aligns their input to the patient journey and utilises their knowledge and skills to the patient9s benefit.
TL;DR: EMS personnel are at high risk of experiencing post-traumatic stress symptoms and early identification and treatment of potential stressors, psychiatric and medical problems is warranted and necessitates ongoing assessment and employee assistance programmes.
Abstract: Background Exposure to traumatic stressors is potentially an integral part of the job for emergency medical services (EMS) personnel, placing them at risk for psychological distress and mental health problems. Study objective The prevalence of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms was examined in a sample of EMS personnel in a multiethnic locality in Hawaii. Commonly encountered traumatic incidents at work were also assessed. Methods The PTSD Check List-Civilian version was sent to 220 EMS personnel. The survey included questions on demographics, traumatic incidents at work, general stressors, coping methods and post-traumatic stress symptoms. Results 105 surveys were returned (48% response rate); 4% of respondents met clinical diagnostic criteria for PTSD, 1% met subclinical criteria for PTSD, 83% reported experiencing some symptoms but no PTSD and 12% had no symptoms. However, few had received treatment for these symptoms. Serious injury or death of a co-worker along with incidents involving children were considered very stressful. General work conditions also contributed to the overall stress levels. Most common coping strategies reported were positive reinterpretation (63%), seeking family and social support (59%) and awareness and venting of emotions (46%), with significant differences by ethnicity. Conclusion EMS personnel are at high risk of experiencing post-traumatic stress symptoms. Early identification and treatment of potential stressors, psychiatric and medical problems is warranted and necessitates ongoing assessment and employee assistance programmes at the minimum.
TL;DR: Stepwise logistic regression analysis found patients aged 75+ years, male, non-Chinese ethnic groups, Sunday and Monday, time of the attendance, distance to ED, chronic obstructive pulmonary disease, heart failure and acute respiratory infections to be significantly associated with frequent attendances.
Abstract: Objective To determine factors associated with frequent emergency department (ED) attendance at an acute general hospital in Singapore. Method Patients who attended the ED from 1 January to 31 December 2006 without prior attendance in the preceding 12 months (index attendance) were tracked for 12 months. Variables included in the analysis were age, gender, race, date and time of attendance, patient acuity category scale, mode of arrival, distance to ED and diagnosis based on ICD-9CM code. Frequent attenders were patients who attended the ED $5 times for any diagnosis within 12 months. Results A total of 82172 patients in the study cohort accounted for a total of 117868 visits within 12 months, of which 35696 (30.3%) were repeat attendances. A total of 1595 patients (1.9%) were frequent attenders responsible for 8% of all repeat attendances. Stepwise logistic regression analysis found patients aged 75+ years, male, non-Chinese ethnic groups, Sunday and Monday, time of the attendance from 16:00 to midnight, distance to ED, chronic obstructive pulmonary disease, heart failure and acute respiratory infections to be significantly associated with frequent attendances. Conclusion With the ageing population and their complex healthcare needs, elderly patients with chronic medical conditions are expected to make up an increasing proportion of the workload of ED in the future. A systems approach and a disease and case management approach in collaboration with primary care providers are interventions recommended to stem this.
TL;DR: The GVL was not used frequently by EPs during the initial two years after its introduction and although the GVL provides a better glottic view, the overall success rates were similar to a CL.
Abstract: Objective To investigate the use and success rates of the GlideScope (GVL) by emergency physicians (EPs) during the initial two years after its introduction. Methods We performed an observational study using registry data of five emergency departments. The success rates in adult patients were evaluated and compared with those of conventional laryngoscope (CL). Results The GVL was used in 345 (10.7%) of 3233 intubation attempts by EPs. The overall success rate of the GVL was not higher than a CL (79.1% vs 77.6%, p=0.538). The success rate for the patients with difficult airway was higher in the GVL than a CL (80.0% vs 50.4%, p Conclusion The GVL was not used frequently by EPs during the initial two years after its introduction. Although the GVL provides a better glottic view, the overall success rates were similar to a CL. The GVL may be useful in patients with difficult airway.
TL;DR: Widespread belief in the benefit of oxygen in AMI may make it difficult to persuade funders of the importance of this issue and health professionals to participate in enrolling patients into a trial in which oxygen would be withheld from half their patients.
Abstract: Introduction There is growing interest in the safety of oxygen therapy in emergency patients. A Cochrane review of oxygen versus air for patients with acute myocardial infarction (AMI) showed a potentially important, but statistically non-significant, increase in mortality (RR 3.03 (95% CI 0.93 to 9.83)) and concluded a definitive randomised controlled trial (RCT) was needed.Objective To explore the feasibility of conducting an RCT of oxygen versus air in AMI, by exploring the beliefs of UK professionals who treat patients with AMI about oxygen's benefits, and to establish a baseline of reported practice by asking about their use of oxygen.Method A cross-sectional online survey of UK emergency department, cardiology and ambulance staff.Result 524 responses were received. All specialities had over 100 respondents. 98.3% said they always or usually use oxygen. 80% reported having local guidelines that recommended the routine use of oxygen. 55% believed oxygen definitely or probably significantly reduces the risk of death, while only 1.3% reported that they thought 'it may even increase the risk of death.' There were only minor differences across specialities and grades.Conclusion Widespread belief in the benefit of oxygen in AMI may make it difficult to persuade funders of the importance of this issue and health professionals to participate in enrolling patients into a trial in which oxygen would be withheld from half their patients.
TL;DR: Interruptions occur commonly during all clinical activities in the ED, and are frequently generated by providers themselves, and have a negative impact on patient satisfaction.
Abstract: Objective To explore the nature of interruptions that occur during clinical practice in the emergency department (ED). We determined the frequency, duration and type of interruptions that occurred. We then determined the impact on patient satisfaction of those interruptions occurring at the bedside. Methods This was a cohort study of ED physicians and physicians in training. Trained research associates were assigned to an individual provider during 4-hour blocks of time during day and evening shifts. The research associates recorded the activity that was interrupted, as well as the nature and the duration of the interruption. If the interruption occurred during the principal interaction with a patient, the patient9s satisfaction score was recorded on a 10-point scale. Results Physicians were commonly interrupted in all clinical activities, but most frequently during reviewing of data (53%) and charting (50%). Bedside interruptions occurred 26% of the time, and had a negative impact on patient satisfaction. The majority of interruptions (60%) were initiated by another healthcare provider (physician or nurse). Interruptions only rarely resulted in a physician changing tasks before completion. Conclusion Interruptions occur commonly during all clinical activities in the ED, and are frequently generated by providers themselves. These have a negative impact on patient satisfaction. The direct impact on medical errors or on provider satisfaction has not been determined.
TL;DR: No instrument assisting clinicians in the diagnostic investigation of patients with suspected acute coronary syndrome consistently fulfils the safety requirements of clinicians.
Abstract: Background Acute chest pain is a frequent reason to attend an emergency room, and various instruments for calculating the probability of an acute coronary syndrome exist. Objective To assess the safety and efficiency of all available instruments investigated in sample validation studies. Methods A systematic review was conducted. Studies were identified describing the development of instruments and all subsequent validations in electronic databases and reference lists of included studies. Inclusion was screened for, full papers checked and data extracted on salient clinical features, performance characteristics and quality in duplicate. Results Of 20 derivation studies, 10 were at least validated once in 14 validations including 26 488 patients. One study by Selker and colleagues was validated in six new patient series and studies by Goldman et al and the Kennedy et al were both validated in three new patient series. All other studies were validated less than three times. In four out of six validations of the Selker et al study, the sensitivity of the prediction rule was 98% or higher. The corresponding values for specificity ranged from 4% to 34%. All remaining prediction rules showed sensitivity values below 95% in all validations. Conclusions No instrument assisting clinicians in the diagnostic investigation of patients with suspected acute coronary syndrome consistently fulfils the safety requirements of clinicians.
TL;DR: The national pilot of clinical performance indicators for English ambulance services will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement.
Abstract: Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008–2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.
TL;DR: The results of this study indicate that β-blockers may prevent increases in heart rate but not hypertensive and adverse effects of MDMA.
Abstract: Background MDMA (3,4-methylenedioxymethamphetamine, ‘Ecstasy’) produces tachycardia and hypertension and is rarely associated with cardiovascular and cerebrovascular complications. In clinical practice, β-blockers are often withheld in patients with stimulant intoxication because they may increase hypertension and coronary artery vasospasm due to loss of β 2 -mediated vasodilation and unopposed α-receptor activation. However, it is unknown whether β-blockers affect the cardiovascular response to MDMA. Methods The effects of the non-selective β-blocker pindolol (20 mg) on the cardiovascular effects of MDMA (1.6 mg/kg) were investigated in a double-blind placebo-controlled crossover study in 16 healthy subjects. Results Pindolol prevented MDMA-induced increases in heart rate. Peak values (mean±SD) for heart rate were 84±13 beats/min after MDMA vs 69±7 beats/min after pindolol-MDMA. In contrast, pindolol pretreatment had no effect on increases in mean arterial blood pressure (MAP) after MDMA. Peak MAP values were 115±11 mm Hg after MDMA vs 114±11 mm Hg after pindolol-MDMA. Pindolol did not change adverse effects of MDMA. Conclusion The results of this study indicate that β-blockers may prevent increases in heart rate but not hypertensive and adverse effects of MDMA.
TL;DR: A 46-year-old man took a lethal dose of an agent called DNP, an illegal weight loss agent used by body builders and freely available on many internet websites, and rapidly deteriorated with profound hyperthermia, acute renal failure, hyperkalaemia, metabolic acidosis and eventually haemodynamic instability.
Abstract: A 46-year-old man took a lethal dose of an agent called dinitrophenol (DNP). He presented 11 h after ingestion with loin pain, diarrhoea and vomiting. He rapidly deteriorated with profound hyperthermia, acute renal failure, hyperkalaemia, metabolic acidosis and eventually haemodynamic instability. Despite aggressive supportive measures and rapid sequence induction, he deteriorated and died 21 h after ingestion. DNP is a metabolic poison that acts by uncoupling oxidative phosphorylation, leading to uncontrolled hyperthermia. It is an illegal weight loss agent that is used by body builders and is freely available on many internet websites. This case highlights the potential for patients to obtain and ingest exotic poisons. A summary of currently recommended treatment and a review of the literature on DNP is included, as well as a discussion of therapies that may be effective in treating hyperthermia in this situation.
TL;DR: It is critical that empirically-based paramedic graduate attributes are developed and agreed upon by both the industry and teaching institutions until this occurs, the national standardisation, accreditation and benchmarking of Australian paramedic education programmes will not be possible.
Abstract: Background The Australian healthcare system at all levels is under increasing pressure. The Australian paramedic discipline has seen a remarkable change in a number of areas including education, training, healthcare identity and clinical practice, particularly over the past three decades. Preparing future healthcare graduates for these expected changes therefore requires careful alignment of graduate attributes to core curriculum. Objectives To establish which graduate attributes best meet the current and future needs of the Australian paramedic discipline. Methods A convenience sample was used for the pilot study involving context experts from paramedic education and training sectors in Australia. Participants rated 56 items using a Likert scale on a paper-based self-reporting questionnaire. Exploratory factor analysis was undertaken on 50 items using principal components analysis (PCA) followed by varimax rotation. Findings A total of 63 content and knowledge experts participated in the study; 40 (63.5%) were male and 23 (36.5%) were female, with 28 (44%) aged 35e44 years. PCA of the 50 items revealed 10 factors with eigenvalues >1, accounting for 77.3% of the total variance. Items with loadings more than 60.40 with the factor in question were used to characterise the factor solutions. Conclusions It is critical that empirically-based paramedic graduate attributes are developed and agreed upon by both the industry and teaching institutions. Until this occurs, the national standardisation, accreditation and benchmarking of Australian paramedic education programmes will not be possible.
TL;DR: POC testing for troponin in the ED tended to reduce the LOS for possible ACS patients, and the degree of this benefit is likely to be markedly dependent on its acceptance and uptake by attending personnel, and on the ED setting in which it is used.
Abstract: Objective To determine the effect of cardiac troponin I testing with a point-of-care (POC) device versus central laboratory on length of stay (LOS) in emergency department (ED) patients presenting with possible acute coronary syndromes (ACS). Methods A 12-week randomised controlled trial at two metropolitan ED in eastern Australia with a combined annual census of 80 000. Participants were all patients presenting with possible ACS. Exclusions were a diagnosis of ACS before arrival, ST elevation and failure to wait for complete assessment. Randomisation was by week when POC was made available. Primary outcome was LOS from patient arrival to physical departure from the ED. The proportion of patients meeting a government target of less than 8 h stay was compared. Analysis was by intention to treat. Results Despite underutilisation of POC, LOS was shorter during weeks when it was available. The time savings translates into approximately 48 minutes (95% CI 12 to 84) per average LOS of almost 7 h, which did not reach statistical significance (p=0.063), or an absolute increase of 10% (95% CI 4.3 to 16.6) in the number of people discharged from the ED within the target LOS of less than 8 h, which did reach significance (p=0.007). These savings were more pronounced in the setting without 24 h central laboratory availability. Conclusions POC testing for troponin in the ED tended to reduce the LOS for possible ACS patients. The degree of this benefit is likely to be markedly dependent on its acceptance and uptake by attending personnel, and on the ED setting in which it is used.
TL;DR: The potential benefits, pitfalls and barriers to adopting e- learning in emergency medicine are described and a blended approach to learning is advocated where e-learning opportunities form an important but limited part of the overall educational experience.
Abstract: This paper describes the potential benefits, pitfalls and barriers to adopting e-learning in emergency medicine. While the benefits relating to access, engagement and quality assurance are clear, caution is urged in embracing e-learning for e-learning's sake. It is argued that, if educational strategies are to change, this must be to the benefit of learners and not just for the convenience of access or record keeping. A variety of e-learning approaches are available, but those that promote group discussion or provide feedback from an educator are more likely to lead to successful learning than stand-alone feedback-free modules. A blended approach to learning is advocated where e-learning opportunities form an important but limited part of the overall educational experience. Shop floor and workshop-based teaching should be enhanced with e-learning, not replaced by it.
TL;DR: Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.
Abstract: Objectives To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene. Methods A training programme was developed to provide medical staff with the skills needed to perform P-FAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular P-FAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department. Results After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed. Conclusion Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.
TL;DR: There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients at the Emergency Department, however, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation.
Abstract: Emergency physicians frequently undertake emergency procedural sedation in non-fasted patients. At present, no UK guidelines exist for pre-procedural fasting in emergency sedation, and guidelines from the North American Association of Anesthesiologists (ASA) designed for general anaesthesia (GA) are extrapolated to emergency care. A systematic review of the literature was conducted with the aim of evaluating the evidence for risk of pulmonary aspiration during emergency procedural sedation in adults. All abstracts were read and relevant articles identified. Further literature was identified by hand-searching reference sections. Papers were objectively evaluated for relevance against pre-determined criteria. The risk of aspiration in emergency procedural sedation is low, and no evidence exists to support pre-procedural fasting. In several large case series of adult and paediatric emergency procedural sedation, non-fasted patients have not been shown to be at increased risk of pulmonary aspiration. There is only one reported case of pulmonary aspiration during emergency procedural sedation, among 4657 adult cases and 17 672 paediatric cases reviewed. Furthermore, ASA guidelines for fasting prior to GA are based on questionable evidence, and there is high-level evidence that demonstrates no link between pulmonary aspiration and non-fasted patients. There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients at the Emergency Department. However, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation.