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Mol S, Gaakeer MI, van der Linden MC, Baan-Kooman ECM, Backus BE, de Ridder VA. Crowding, perceived crowding and workload in Dutch emergency departments: should we continue on the same road? Eur J Emerg Med 2023; 30:229-230. [PMID: 37115965 DOI: 10.1097/mej.0000000000001034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Sander Mol
- Emergency Department, Franciscus Gasthuis & Vlietland, Rotterdam
| | | | | | | | - Barbra E Backus
- Emergency Department, Franciscus Gasthuis & Vlietland, Rotterdam
| | - Victor A de Ridder
- Emergency Department, Department of Trauma Surgery and Pediatric Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med 2023; 51:881-891. [PMID: 36951452 PMCID: PMC10262984 DOI: 10.1097/ccm.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN International multicenter cohort study. SETTING Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
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Affiliation(s)
- Bart Gerard Jan Candel
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | | | - Mikkel Brabrand
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South-West Jutland, Esbjerg, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Candel BGJ, Raven W, Nissen SK, Morsink MEB, Gaakeer MI, Brabrand M, van Zwet EW, de Jonge E, de Groot B. THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY. J Emerg Med 2023:S0736-4679(23)00255-X. [PMID: 37394368 DOI: 10.1016/j.jemermed.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/25/2023] [Accepted: 04/10/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Marlies E B Morsink
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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van den Brand CL, Foks KA, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MG, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Dippel DW, Jellema K. Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series. Injury 2022; 53:2979-2987. [PMID: 35831208 DOI: 10.1016/j.injury.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.
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Affiliation(s)
- Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands; Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, ADRZ, PO Box 15, 4460 AA Goes, the Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, PO 90153, 5200 ME 's-Hertogenbosch, the Netherlands
| | - Myriam Gm Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Eef Reijners
- formerly Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Meriam Braaksma
- Department of Neurology, Bravis Hospital, PO Box 999, 4624 VT Bergen op Zoom, the Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC Tilburg, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, PO Box 432, 2501 CK The Hague, the Netherlands
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Raven W, van den Hoven EMP, Gaakeer MI, Ter Avest E, Sir O, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, Nickel CH, de Groot B. The association between presenting complaints and clinical outcomes in emergency department patients of different age categories. Eur J Emerg Med 2022; 29:33-41. [PMID: 34406137 DOI: 10.1097/mej.0000000000000860] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND IMPORTANCE Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent. OBJECTIVE To assess the frequency and association of PCs with hospitalization and mortality across age categories. METHODS An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs). RESULTS We included 172 104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)]. CONCLUSIONS Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality.
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Affiliation(s)
- Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
| | | | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Centre Groningen, Groningen
| | - Ozcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden
| | | | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
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Candel BGJ, Khoudja J, Gaakeer MI, Ter Avest E, Sir Ö, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, de Groot B. Age-adjusted interpretation of biomarkers of renal function and homeostasis, inflammation, and circulation in Emergency Department patients. Sci Rep 2022; 12:1556. [PMID: 35091652 PMCID: PMC8799641 DOI: 10.1038/s41598-022-05485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/12/2022] [Indexed: 12/03/2022] Open
Abstract
Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to (patho)-physiologic changes. The aim of this study was therefore to assess the effect of age on the case-mix adjusted association between biomarkers of renal function and homeostasis, inflammation and circulation and in-hospital mortality. This observational multi-center cohort study has used the Netherlands Emergency department Evaluation Database (NEED), including all consecutive ED patients ≥ 18 years of three hospitals. A generalized additive logistic regression model was used to visualize the association between in-hospital mortality, age and five blood tests (creatinine, sodium, leukocytes, C-reactive Protein, and hemoglobin). Multivariable logistic regression analyses were used to assess the association between the number of abnormal blood test values and mortality per age category (18-50; 51-65; 66-80; > 80 years). Of the 94,974 included patients, 2550 (2.7%) patients died in-hospital. Mortality increased gradually for C-reactive Protein (CRP), and had a U-shaped association for creatinine, sodium, leukocytes, and hemoglobin. Age significantly affected the associations of all studied blood tests except in leukocytes. In addition, with increasing age categories, case-mix adjusted mortality increased with the number of abnormal blood tests. In summary, the association between blood tests and (adjusted) mortality depends on age. Mortality increases gradually or in a U-shaped manner with increasing blood test values. Age-adjusted numerical scores may improve risk stratification. Our results have implications for interpretation of blood tests and their use in risk stratification tools and acute care guidelines.Trial registration number Netherlands Trial Register (NTR) NL8422, 03/2020.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Jamèl Khoudja
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, 's-Gravenpolderseweg 114, 4462 RA, Goes, The Netherlands
| | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Center Groningen, Hanzeplein1, 9713 GZ, Groningen, The Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Center, Houtlaan 4, 6525 XZ, Nijmegen, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Roger A P A Hessels
- Department of Emergency Medicine, Elisabeth-TweeSteden Hospital, Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Candel BG, Duijzer R, Gaakeer MI, Ter Avest E, Sir Ö, Lameijer H, Hessels R, Reijnen R, van Zwet EW, de Jonge E, de Groot B. The association between vital signs and clinical outcomes in emergency department patients of different age categories. Emerg Med J 2022; 39:903-911. [PMID: 35017189 DOI: 10.1136/emermed-2020-210628] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/07/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category. AIMS To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories. METHODS Observational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81-100, 101-120, 121-140, >140 mm Hg). RESULTS We included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients. CONCLUSION For SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.
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Affiliation(s)
- Bart Gj Candel
- Emergency Department, Maxima Medical Centre, Veldhoven, Noord-Brabant, The Netherlands .,Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Renée Duijzer
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Menno I Gaakeer
- Emergency Department, Admiraal De Ruyter Hospital, Goes, Zeeland, The Netherlands
| | - Ewoud Ter Avest
- Emergency Department, University Medical Centre Groningen, Groningen, The Netherlands
| | - Özcan Sir
- Emergency Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Heleen Lameijer
- Emergency Department, Medical Centre Leeuwarden, Leeuwarden, Friesland, The Netherlands
| | - Roger Hessels
- Emergency Department, Elisabeth-TweeSteden Hospital, Tilburg, Noord-Brabant, The Netherlands
| | - Resi Reijnen
- Emergency Department, Medical Centre Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden Universitair Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Evert de Jonge
- Intensive Care, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
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8
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Candel BG, Dap S, Raven W, Lameijer H, Gaakeer MI, de Jonge E, de Groot B. Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study. Eur J Intern Med 2022; 95:74-79. [PMID: 34521584 DOI: 10.1016/j.ejim.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). METHODS Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. RESULTS Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. CONCLUSIONS Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.
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Affiliation(s)
- Bart Gj Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands; Department of Emergency Medicine, Máxima Medical Center, De Run 4600, Veldhoven, DB 5504, the Netherlands.
| | - Saimi Dap
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, AD 8934, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Adrz Hospital, 's-Gravenpolderseweg 114, Goes, RA 4462, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
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9
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Schmitz D, Vos M, Stolmeijer R, Lameijer H, Schönberger T, Gaakeer MI, de Groot B, Eikendal T, Wansink L, Ter Avest E. Association between personal protective equipment and SARS-CoV-2 infection risk in emergency department healthcare workers. Eur J Emerg Med 2021; 28:202-209. [PMID: 33105329 PMCID: PMC8081446 DOI: 10.1097/mej.0000000000000766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND IMPORTANCE Healthcare personnel working in the emergency department (ED) is at risk of acquiring severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2). So far, it is unknown if the reported variety in infection rates among healthcare personnel is related to the use of personal protective equipment (PPE) or other factors. OBJECTIVE The aim of this study was to investigate the association between PPE use and SARS-CoV-2 infections among ED personnel in the Netherlands. DESIGN, SETTING AND PARTICIPANTS A nationwide survey, consisting of 42 questions about PPE-usage, ED layout - and workflow and SARS-CoV-2 infection rates of permanent ED staff, was sent to members of the Dutch Society of Emergency Physicians. Members were asked to fill out one survey on behalf of the ED of their hospital. The association between PPE use and the infection rate was investigated using univariable and multivariable regression analyses, adjusting for potential confounders. OUTCOME MEASURES Primary outcome was the incidence of confirmed SARS-CoV-2 infections among permanent ED staff between 1 March and 15 May 2020. RESULTS Surveys were sent to 64 EDs of which 45 responded (70.3%). In total, 164 ED staff workers [5.1 (3.2-7.0)%] tested positive for COVID-19 during the study period compared to 0.087% of the general population. There was significant clustering of infected ED staff in some hospitals (range: 0-23 infection). In 13 hospitals, an FFP2 (filtering facepiece particles >94% aerosol filtration) mask or equivalent and eye protection was worn for all contacts with patients with suspected or confirmed SARS-CoV-2 during the whole study period. The unadjusted staff infection rate was higher in these hospitals [7.3 (3.4-11.1) vs. 4.0 (1.9-6.1)%, absolute difference + 3.3%]. Hospital staff testing policy was identified as a potential confounder of the relation between PPE use and confirmed SARS-CoV-2 infections (collinearity statistic 0.95). After adjusting for hospital testing policy, type of PPE was not associated with incidence of COVID 19 infections among ED staff (P = 0.40). CONCLUSION In this cross-sectional study, the use of high-level PPE (FFP2 or equivalent and eye protection) by ED personnel during all contacts with patients with suspected or confirmed SARS-CoV-2 does not seem to be associated with a lower infection rate of ED staff compared to lower level PPE use. Attention should be paid to ED layout and social distancing to prevent cross-contamination of ED personnel.
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Affiliation(s)
- Danique Schmitz
- Department of Emergency Medicine, University Medical Center Groningen, Groningen
| | - Marieke Vos
- Department of Emergency Medicine, University Medical Center Groningen, Groningen
| | - Renate Stolmeijer
- Department of Emergency Medicine, University Medical Center Groningen, Groningen
| | | | | | | | | | | | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Center Groningen, Groningen
- Air Ambulance Trust Kent, Surrey and Sussex, UK
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10
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Klokman VW, Barten DG, Peters NALR, Versteegen MGJ, Wijnands JJJ, van Osch FHM, Gaakeer MI, Tan ECTH, Boin A. A scoping review of internal hospital crises and disasters in the Netherlands, 2000-2020. PLoS One 2021; 16:e0250551. [PMID: 33901248 PMCID: PMC8075216 DOI: 10.1371/journal.pone.0250551] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Internal hospital crises and disasters (IHCDs) are events that disrupt the routine functioning of a hospital while threatening the well-being of patients and staff. IHCDs may cause hospital closure, evacuations of patients and loss of healthcare capacity. The consequences may be ruinous for local communities. Although IHCDs occur with regularity, information on the frequency and types of these events is scarcely published in the medical literature. However, gray literature and popular media reports are widely available. We therefore conducted a scoping review of these literature sources to identify and characterize the IHCDs that occurred in Dutch hospitals from 2000 to 2020. The aim is to develop a systematic understanding of the frequency of the various types of IHCDs occurring in a prosperous nation such as the Netherlands. METHODS A systematic scoping review of news articles retrieved from the LexisNexis database, Google, Google News, PubMed and EMBASE between 2000 and 2020. All articles mentioning the closure of a hospital department in the Netherlands were analyzed. RESULTS A total of 134 IHCDs were identified in a 20-year time period. Of these IHCDs, there were 96 (71.6%) emergency department closures, 76 (56.7%) operation room closures, 56 (41.8%) evacuations, 26 (17.9%) reports of injured persons, and 2 (1.5%) reported casualties. Cascading events of multiple failures transpired in 39 (29.1%) IHCDs. The primary causes of IHCDs (as reported) were information and communication technology (ICT) failures, technical failures, fires, power failures, and hazardous material warnings. An average of 6.7 IHCDs occurred per year. From 2000-2009 there were 32 IHCDs, of which one concerned a primary ICT failure. Of the 102 IHCDs between 2010-2019, 32 were primary ICT failures. CONCLUSIONS IHCDs occur with some regularity in the Netherlands and have marked effects on hospital critical care departments, particularly emergency departments. Cascading events of multiple failures transpire nearly a third of the time, limiting the ability of a hospital to stave off closure due to failure. Emergency managers should therefore prioritize the risk of ICT failures and cascading events and train hospital staff accordingly.
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Affiliation(s)
- Vincent W. Klokman
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Dennis G. Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | | | | | | | - Frits H. M. van Osch
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Menno I. Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | - Edward C. T. H. Tan
- Department of Trauma Surgery and Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjen Boin
- Department of Political Science, Leiden University, Leiden, The Netherlands
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11
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Veugelers R, Gaakeer MI, Patka P, Huijsman R. Improving design choices in Delphi studies in medicine: the case of an exemplary physician multi-round panel study with 100% response. BMC Med Res Methodol 2020; 20:156. [PMID: 32539717 PMCID: PMC7294633 DOI: 10.1186/s12874-020-01029-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background A proper application of the Delphi technique is essential for obtaining valid research results. Medical researchers regularly use Delphi studies, but reports often lack detailed information on methodology and controlled feedback: in the medical literature, papers focusing on Delphi methodology issues are rare. Since the introduction of electronic surveys, details on response times remain scarce. We aim to bridge a number of gaps by providing a real world example covering methodological choices and response times in detail. Methods The objective of our e(lectronic)-Delphi study was to determine minimum standards for emergency departments (EDs) in the Netherlands. We opted for a two-part design with explicit decision rules. Part 1 focused on gathering and defining items; Part 2 addressed the main research question using an online survey tool. A two-person consensus rule was applied throughout: even after consensus on specific items was reached, panellists could reopen the discussion as long as at least two panellists argued similarly. Per round, the number of reminders sent and individual response times were noted. We also recorded the methodological considerations and evaluations made by the research team prior to as well as during the study. Results The study was performed in eight rounds and an additional confirmation round. Response rates were 100% in all rounds, resulting in 100% consensus in Part 1 and 96% consensus in Part 2. Our decision rules proved to be stable and easily applicable. Items with negative advice required more rounds before consensus was reached. Response delays were mostly due to late starts, but once panellists started, they nearly always finished the questionnaire on the same day. Reminders often yielded rapid responses. Intra-individual differences in response time were large, but quick responders remained quick. Conclusions We advise those considering Delphi study to follow the CREDES guideline, consider a two-part design, invest in personal commitment of the panellists, set clear decision rules, use a consistent lay-out and send out your reminders early. Adopting this overall approach may assist researchers in future Delphi studies and may help to improve the quality of Delphi designs in terms of improved rigor and higher response rates.
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Affiliation(s)
- Rebekka Veugelers
- Emergency Department, Adrz hospital, P.O. Box 15 4460, AA, Goes, the Netherlands.
| | - Menno I Gaakeer
- Emergency Department, Adrz hospital, P.O. Box 15 4460, AA, Goes, the Netherlands
| | - Peter Patka
- Emergency Department, Erasmus MC, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Robbert Huijsman
- Erasmus School of Health Policy & Management, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands
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12
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Panneman MJM, Blatter BM, Gaakeer MI, Jansen T, van Beeck EF. [Decrease in minor injury related visits to Emergency Departments coincides with higher numbers of primary care contacts]. Ned Tijdschr Geneeskd 2020; 164:D4867. [PMID: 32749797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital admission. We investigated how the number of injury-related emergency department visits and GP contacts evolved over the period 2013-2017. DESIGN Retrospective observational trend study. METHOD To calculate the trend in emergency department visits in the Netherlands, we used data from the injury information system (LIS) for the period 2013-2017. To calculate the trend in GP contacts (GP practices as well as GP centres), we used data from the NivelZorgregistraties (Nivel medical records). In order to compare the trends, we distinguished between minor and major injuries. The numbers from the records were extrapolated to numbers for the whole of the Netherlands. RESULTS In the period studied, the number of patients with minor injuries who visited the ED dropped by 38.5%, while the number of patients with major injuries (fractures and brain injuries) increased by 4.1%. In the same period, the number of GP contacts for minor injuries at GP practices increased by 25% and at GP centres by 43%; the number of primary care contacts for major injuries increased by 5.1% (GP practices) and 31% (GP centres) respectively. CONCLUSION The role of general practitioners in the treatment of patients with minor injuries is increasing. The trend in major injuries is a better indicator for monitoring accidents and violence in the Netherlands. Conflict of interest and financial support: none declared.
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Affiliation(s)
| | | | | | | | - Ed F van Beeck
- Erasmus MC, afd. Maatschappelijke Gezondheidszorg, Rotterdam
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13
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Foks KA, Dijkland SA, Lingsma HF, Polinder S, van den Brand CL, Jellema K, Jacobs B, van der Naalt J, Sir Ö, Jie KE, Schoonman GG, Hunink MG, Steyerberg EW, Dippel DW, Gaakeer MI, Schutte CE, Visee HF, den Boogert H, Reijners E, Braaksma M, de Jong E, Patka P. Risk of Intracranial Complications in Minor Head Injury: The Role of Loss of Consciousness and Post-Traumatic Amnesia in a Multi-Center Observational Study. J Neurotrauma 2019; 36:2377-2384. [DOI: 10.1089/neu.2018.6354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelly A. Foks
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Simone A. Dijkland
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Crispijn L. van den Brand
- Department of Emergency Medicine, Haaglanden Medical Center, the Hague, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim E. Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Guus G. Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, the Netherlands
| | - Myriam G.M. Hunink
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands
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14
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Gaakeer MI, Veugelers R, van Lieshout JM, Patka P, Huijsman R. The emergency department landscape in The Netherlands: an exploration of characteristics and hypothesized relationships. Int J Emerg Med 2018; 11:35. [PMID: 31179931 PMCID: PMC6134940 DOI: 10.1186/s12245-018-0196-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 08/26/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Nationwide optimization of the emergency department (ED) landscape is being discussed in The Netherlands. The emphasis is put mostly on the number of EDs actually present at the time versus a proposed minimum number of EDs needed in the future. The predominant idea in general is that by concentrating emergency care in less EDs costs would be saved and quality of care would increase. However, structural insight into similarities as well as differences of ED characteristics is missing. This knowledge and fact interpretation is needed to provide better steering information which could contribute to strategies aiming to optimize the ED landscape. This study provides an in-depth insight in the ED landscape of The Netherlands by presentation of providing an overview of the variation in ED characteristics and by exploring associations between ED volume characteristics on one side and measures of available ED and hospital resources on the other side. Obtained insight can be a starting point towards a more well-founded future optimization policy. METHODS This is a nationwide cross-sectional observational study. All 24/7 operational EDs meeting the IFEM definition in The Netherlands in December 2016 were identified, contacted and surveyed. Requested information was retrieved from local hospital information systems and entered into a database. Till August 1, 2017, data have been collected. RESULTS All 87 eligible EDs in The Netherlands participated in this study (100%). All of them were hospital based. These were 8 EDs in universities (9%), 27 EDs in teaching hospitals (31%) and 52 EDs in general hospitals (60%). On average, 22,755 patients were seen per ED (range 6082-53,196). On average, 85% (range 44-99%) was referred versus 15% self-referred (range 1-56%). Further subdivision of the referred patients showed 17% 'emergency call' (range 0.5-30%), 52% by GPC (range 16-77%) and 15% other referral (range 1-52%). On average, 38% of patients per ED (range 13-76%) were hospitalized. ED treatment bays ranged from 4 to 36 and added nationally up to 1401 (mean and median of 16 per ED). The number of hospital beds behind these EDs ranged from 104 to 1339 and added up to 36,630 beds nationally (mean of 421 and median of 375 behind each ED). Information about ED nurse workforce was available for 83 of 87 EDs and ranged from 11 to 65, adding up to 2348 fulltime-equivalent nationally (mean of 28 and median of 27 per ED). We found positive and significant correlations, confirming all formulated hypotheses. The strongest correlation was seen between the number of patients seen in the ED and ED nurse workforce, followed by the number of patients seen in the ED and ED treatment bays. The other hypotheses showed less positive significant correlations. CONCLUSION Our study shows that the ED landscape is still pluriform by numbers and specifications of individual ED locations. This study identifies associations between patient and hospitalization volumes on a national level on one side and number of ED treatment bays, ED nurse workforce capacity and available hospital beds on the other side. These findings might be useful as input for the development of an ED resource allocation framework and a more targeted optimization policy in the future.
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Affiliation(s)
- Menno I. Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, The Netherlands
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rebekka Veugelers
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Joris M. van Lieshout
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robbert Huijsman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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15
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Foks KA, van den Brand CL, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, den Boogert HF, Sir Ö, Patka P, Polinder S, Gaakeer MI, Schutte CE, Jie KE, Visee HF, Hunink MGM, Reijners E, Braaksma M, Schoonman GG, Steyerberg EW, Jellema K, Dippel DWJ. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362:k3527. [PMID: 30143521 PMCID: PMC6108278 DOI: 10.1136/bmj.k3527] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To externally validate four commonly used rules in computed tomography (CT) for minor head injury. DESIGN Prospective, multicentre cohort study. SETTING Three university and six non-university hospitals in the Netherlands. PARTICIPANTS Consecutive adult patients aged 16 years and over who presented with minor head injury at the emergency department with a Glasgow coma scale score of 13-15 between March 2015 and December 2016. MAIN OUTCOME MEASURES The primary outcome was any intracranial traumatic finding on CT; the secondary outcome was a potential neurosurgical lesion on CT, which was defined as an intracranial traumatic finding on CT that could lead to a neurosurgical intervention or death. The sensitivity, specificity, and clinical usefulness (defined as net proportional benefit, a weighted sum of true positive classifications) of the four CT decision rules. The rules included the CT in head injury patients (CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and National Institute for Health and Care Excellence (NICE) guideline for head injury. RESULTS For the primary analysis, only six centres that included patients with and without CT were selected. Of 4557 eligible patients who presented with minor head injury, 3742 (82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT, and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC); specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from 4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for performing CT scanning: the NOC rule was preferable at a low threshold, the NICE rule was preferable at a higher threshold, whereas the CHIP rule was preferable for an intermediate threshold. CONCLUSIONS Application of the CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT scanning among patients with minor head injury, resulting in many unnecessary CT scans and some missed intracranial traumatic findings. Until an existing decision rule has been updated, any of the four rules can be used for patients presenting minor head injuries at the emergency department. Use of the CHIP rule is recommended because it leads to a substantial reduction in CT scans while missing few potential neurosurgical lesions.
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Affiliation(s)
- Kelly A Foks
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Crispijn L van den Brand
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Eline de Jong
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague, Netherlands
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Charlotte E Schutte
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
| | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Huib F Visee
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Myriam G M Hunink
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Centre for Health Decision Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Eef Reijners
- Department of Emergency Medicine, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Meriam Braaksma
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
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16
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Pierik JGJ, IJzerman MJ, Gaakeer MI, Vollenbroek-Hutten MMR, Doggen CJM. Painful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients' Pain by Nurses. J Emerg Nurs 2017; 43:228-238. [PMID: 28359711 DOI: 10.1016/j.jen.2016.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/14/2016] [Accepted: 10/19/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Unrelieved acute musculoskeletal pain continues to be a reality of major clinical importance, despite advancements in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Yet inaccurate pain assessment is a consistent finding worldwide in various clinical settings, including the emergency department. In this study, pain assessments between nurses and patients with acute musculoskeletal pain after extremity injury will be compared to assess discrepancies. A second aim is to identify patients at high risk for underassessment by emergency nurses. METHODS The prospective PROTACT study included 539 adult patients who were admitted to the emergency department with musculoskeletal pain. Data on pain assessment and characteristics of patients including demographics, pain, and injury, psychosocial, and clinical factors were collected using questionnaires and hospital registry. RESULTS Nurses significantly underestimated patients' pain with a mean difference of 2.4 and a 95% confidence interval of 2.2-2.6 on an 11-points numerical rating scale. Agreement between nurses' documented and patients' self-reported pain was only 27%, and 63% of the pain was underassessed. Pain was particularly underassessed in women, in persons with a lower educational level, in patients who used prehospital analgesics, in smokers, in patients with injury to the lower extremities, in anxious patients, and in patients with a lower urgency level. DISCUSSION Underassessment of pain by emergency nurses is still a major problem and might result in undertreatment of pain if the emergency nurses rely on their assessment to provide further pain treatment. Strategies that focus on awareness among nurses of which patients are at high risk of underassessment of pain are needed.
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Nijk PD, van Rees Vellinga TP, van Lieshout JM, Gaakeer MI. [Diving accident-induced arterial gas embolism]. Ned Tijdschr Geneeskd 2017; 161:D1459. [PMID: 28880140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND During scuba diving, nitrogen dissolves into the body tissues due to elevated pressure under water. During a sudden drop in pressure due to a rapid return to the water surface, arterial gas embolism can arise from pulmonary barotrauma. In a later phase, nitrogen bubbles can also arise in the venous circulation (decompression sickness). Arterial bubbles can incur vascular damage, obstruction, hypoxia and infarction. CASE DESCRIPTION A 53-year-old healthy sport diver presented at the emergency department in a hypovolemic shock with progressive paresis of all the extremities. He had made an emergency ascent from a depth of 47 meter. During recompression therapy his condition deteriorated. It transpired that he had an patent foramen ovale. As a consequence of this, nitrogen bubbles due to decompression sickness entered the arterial circulation. Despite maximum therapeutic intervention the patient remained paretic. CONCLUSION After an ill-fated dive, this patient with patent foramen ovale contracted arterial gas embolism due to pulmonary barotrauma and, at a later stage, decompression sickness. There was increasing damage to the spinal cord resulting in severe physiological disruption.
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Affiliation(s)
- P D Nijk
- Admiraal De Ruyter Ziekenhuis, afd. Spoedeisende Geneeskunde, Goes
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Smithuis JW, Gips E, van Rees Vellinga TP, Gaakeer MI. Diving accidents: a cohort study from the Netherlands. Int J Emerg Med 2016; 9:14. [PMID: 26968856 PMCID: PMC4788674 DOI: 10.1186/s12245-016-0109-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 03/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background Diving is, besides professional reasons, an increasingly popular leisure activity. Whilst statistically compared to other sports safe, diving accidents can result in serious complications. In order to treat this specific patient category adequately, early diagnosis is important. In this study, we explore various medical aspects of diving accidents. By sharing our experiences, we intend to create awareness and enhance urgent medical care for this specific category of patients. Methods We conducted a retrospective cohort study using anonymized patient records from the emergency department (ED) of the Admiraal De Ruyter Hospital (ADRZ) and affiliated Medical Centre Hyperbaric Oxygen Therapy (MCHZ1) both in Goes, Netherlands. We evaluated all patients that presented to our ED as a diving accident from 1 November 2011 to 30 August 2015. Results In the selected period, 43 patients presented to our ED with complaints after diving; 84 % were male and 49 % older than 40 years, and they came by ambulance or referred by a general practitioner or other medical centres in the area; 70 % presented the same date as their dive, 21 % 1 to 3 days and 9 % later than 3 days after having dived. Pain was the most frequently reported symptom (44 %), followed by constitutional symptoms (42 %). Numbness or paraesthesia was reported in 33 %. Respiratory symptoms, dizziness, a change in mental status (e.g. apathy, confused or restlessness) and problems with coordination were present in 10–21 % of the cases. Symptoms that were apparent in less than 10 % of the cases were cutis marmorata, visual or auditory complaints, muscle weakness, cardiovascular symptoms or a malfunction of the anal sphincter or urinary bladder. Most of our patients exhibited more than one symptom; 70 % of all patients received hyperbaric oxygen recompression therapy. Conclusions The limited number of patients presenting with complaints after a diving incident, the difficulty of recognition and the (potential) huge impact if not recognized and treated adequately make us believe that every diving accident should be discussed with a centre of expertise.
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Affiliation(s)
- J W Smithuis
- Department of Emergency Medicine, VU University Medical Center, Amsterdam, Netherlands.
| | - E Gips
- Department of Emergency Medicine, Fiona Stanley Hospital, Murdoch, Perth, Western Australia
| | | | - M I Gaakeer
- Department of Emergency Medicine, Admiraal De Ruyter Hospital, Goes, Netherlands
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Pierik JGJ, Berben SA, IJzerman MJ, Gaakeer MI, van Eenennaam FL, van Vugt AB, Doggen CJM. A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain. Int Emerg Nurs 2016; 27:3-10. [PMID: 26968352 DOI: 10.1016/j.ienj.2016.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 11/16/2022]
Abstract
While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre-post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients' self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P < 0.05), whereas time to opioids decreased from 37 to 15 min (P < 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.
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Affiliation(s)
- Jorien G J Pierik
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands.
| | - Sivera A Berben
- Regional Emergency Healthcare Network, Radboud University Medical Center, Nijmegen, Netherlands; Faculty of Health and Social Studies, Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, Netherlands
| | - Maarten J IJzerman
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands
| | - Menno I Gaakeer
- Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, Netherlands
| | - Fred L van Eenennaam
- Ambulance Oost, Hengelo, Netherlands; Anesthesiology, Ziekenhuisgroep Twente, Almelo, Netherlands
| | - Arie B van Vugt
- Emergency Department, Medisch Spectrum Twente, Enschede, Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands
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20
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Gaakeer MI, van den Brand CL, Gips E, van Lieshout JM, Huijsman R, Veugelers R, Patka P. [National developments in Emergency Departments in the Netherlands: numbers and origins of patients in the period from 2012 to 2015]. Ned Tijdschr Geneeskd 2016; 160:D970. [PMID: 28000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Gaining insight into key figures of emergency departments (EDs) in the Netherlands and developments in these figures. DESIGN Longitudinal survey study. METHOD Over the period from 2012 up to and including 2015, the following key data were surveyed: number of EDs, number of ED patients, ED patients' origin, number of hospital admissions from the ED and form of cooperation between ED and a general practitioner centre (GPC). RESULTS An average of 96% of all EDs responded. The number of EDs decreased from 93 to 87. The percentage of EDs that maintained a form of cooperation with a GPC in the hospital rose from 49% to 79%. The total number of patients seen annually in an ED in the Netherlands decreased by 128,000 to 1.951 million. The proportion of patients presenting in the ED via ambulance, mobile medical team or 112 (emergency number) increased by 2.6% to 16.0%. The proportion of patients referred from their own GP or GPCs increased by 7.8% to an average of 50.3%. The proportion of self-referrals decreased by 12.6% to 17.4%. The proportion of patients who came up to the ED through a different route remained constant at around 14%. The nationwide variation in the origin of patients remained high. The average percentage of hospital admissions from the ED increased by 5.6% to 37.2%. CONCLUSION The number of EDs is decreasing and the cooperation between EDs and GPCs has intensified. The number of patients seen in the ED has decreased. The percentage of self-referrals has decreased and the number of hospital admissions from the ED has increased significantly. For a successful and consistent policy, more substantive data on the nature and extent of emergency care in the ED are needed. This requires a national registry.
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Affiliation(s)
- M I Gaakeer
- Admiraal De Ruyter Ziekenhuis, afd. Spoedeisende Hulp, Goes
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21
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Pierik JGJ, IJzerman MJ, Gaakeer MI, Vollenbroek-Hutten MMR, van Vugt AB, Doggen CJM. Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury. Eur J Pain 2015; 20:711-22. [PMID: 26492564 DOI: 10.1002/ejp.796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. METHODS The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. RESULTS At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. CONCLUSIONS Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.
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Affiliation(s)
- J G J Pierik
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - M J IJzerman
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - M I Gaakeer
- Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, The Netherlands
| | - M M R Vollenbroek-Hutten
- Biomedical Signals and Systems, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - A B van Vugt
- Emergency Department and Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - C J M Doggen
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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22
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Mortelmans LJM, Bouman SJM, Gaakeer MI, Dieltiens G, Anseeuw K, Sabbe MB. Dutch senior medical students and disaster medicine: a national survey. Int J Emerg Med 2015; 8:77. [PMID: 26335099 PMCID: PMC4558995 DOI: 10.1186/s12245-015-0077-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/16/2015] [Indexed: 11/15/2022] Open
Abstract
Background Medical students have been deployed in victim care of several disasters throughout history. They are corner stones in first-line care in recent pandemic planning. Furthermore, every physician and senior medical student is expected to assist in case of disaster situations, but are they educated to do so? Being one of Europe’s densest populated countries with multiple nuclear installations, a large petrochemical industry and also at risk for terrorist attacks, The Netherlands bear some risks for incidents. We evaluated the knowledge on Disaster Medicine in the Dutch medical curriculum. Our hypothesis is that Dutch senior medical students are not prepared at all. Methods Senior Dutch medical students were invited through their faculty to complete an online survey on Disaster Medicine, training and knowledge. This reported knowledge was tested by a mixed set of 10 theoretical and practical questions. Results With a mean age of 25.5 years and 60 % females, 999 participants completed the survey. Of the participants, 51 % considered that Disaster Medicine should absolutely be taught in the regular medical curriculum and only 2 % felt it as useless; 13 % stated to have some knowledge on disaster medicine. Self-estimated capability to deal with various disaster situations varied from 1.47/10 in nuclear incidents to 3.92/10 in influenza pandemics. Self-estimated knowledge on these incidents is in the same line (1.71/10 for nuclear incidents and 4.27/10 in pandemics). Despite this limited knowledge and confidence, there is a high willingness to respond (ranging from 4.31/10 in Ebola outbreak over 5.21/10 in nuclear incidents to 7.54/10 in pandemics). The case/theoretical mix gave a mean score of 3.71/10 and raised some food for thought. Although a positive attitude, 48 % will place contaminated walking wounded in a waiting room and 53 % would use iodine tablets as first step in nuclear decontamination. Of the participants, 52 % even believes that these tablets protect against external radiation, 41 % thinks that these tablets limit radiation effects more than shielding and 57 % believes that decontamination of chemical victims consists of a specific antidote spray in military cabins. Conclusions Despite a high willingness to respond, our students are not educated for disaster situations. Electronic supplementary material The online version of this article (doi:10.1186/s12245-015-0077-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc J M Mortelmans
- Department of Emergency Medicine ZNA camp Stuivenberg, Lange Beeldekensstraat 267, B2060, Antwerp, Belgium,
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Pierik JGJ, IJzerman MJ, Gaakeer MI, Berben SA, van Eenennaam FL, van Vugt AB, Doggen CJM. Pain management in the emergency chain: the use and effectiveness of pain management in patients with acute musculoskeletal pain. Pain Med 2014; 16:970-84. [PMID: 25546003 DOI: 10.1111/pme.12668] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE While acute musculoskeletal pain is a frequent complaint in emergency care, its management is often neglected, placing patients at risk for insufficient pain relief. Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department (ED) and how this affects pain relief. A secondary goal is to identify prognostic factors for clinically relevant pain relief. DESIGN This prospective study (PROTACT) includes 697 patients admitted to ED with musculoskeletal extremity injury. Data regarding pain, injury, and pain management were collected using questionnaires and registries. RESULTS Although 39.9% of the patients used analgesics in the prehospital phase, most patients arrived at the ED with severe pain. Despite the high pain prevalence in the ED, only 35.7% of the patients received analgesics and 12.5% received adequate analgesic pain management. More than two-third of the patients still had moderate to severe pain at discharge. Clinically relevant pain relief was achieved in only 19.7% of the patients. Pain relief in the ED was higher in patients who received analgesics compared with those who did not. Besides analgesics, the type of injury and pain intensity on admission were associated with pain relief. CONCLUSIONS There is still room for improvement of musculoskeletal pain management in the chain of emergency care. A high percentage of patients were discharged with unacceptable pain levels. The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief. Additional research in these areas is needed.
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Affiliation(s)
- Jorien G J Pierik
- Health Technology & Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede
| | - Maarten J IJzerman
- Health Technology & Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede
| | | | - Sivera A Berben
- Regional Emergency Healthcare Network, Radboud University Nijmegen, Nijmegen.,Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen
| | | | - Arie B van Vugt
- Emergency Department and Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede
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24
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Gaakeer MI, van den Brand CL, Veugelers R, Patka P. [Inventory of attendance at Dutch emergency departments and self-referrals]. Ned Tijdschr Geneeskd 2014; 158:A7128. [PMID: 24867482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To make an inventory of annual attendance at emergency departments (A&E) in the Netherlands. DESIGN Inventorisation study in all Dutch A & E departments. METHOD All A& E departments in the Netherlands that were operational for 24 hours a day, 7 days a week in December 2012 were approached (n = 93) and the following data were collected over 2012: the total number of patients, the number of hospital admissions through the A & E department, and the number of self-referrals. RESULTS Data were obtained from 96% emergency departments (n = 89) throughout the Netherlands, including all 8 university medical centres and 28 hospitals of the association of tertiary medical teaching hospitals (STZ). In 2012 a total of 1,989,746 people attended the 89 emergency departments. The average percentage of hospital admissions from an A & E department was 32% nationwide (range: 8-54). The average percentage of self-referrals to the emergency departments was 30% nationwide (range: 3-76). CONCLUSION The number of attendees at A & E, the admission rate through the A & E department and percentage of self-referrals in 2012 showed a range of variation nationwide. The number of people attending A & E has not increased over the last few years and is low in international terms. On average one-third of people attending A & E were admitted. In contrast with prevailing national beliefs,a minority of attendees at A &E departments were self-referrals.
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25
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Gaakeer MI, van den Brand CL, Bracey A, van Lieshout JM, Patka P. Emergency medicine training in the Netherlands, essential changes needed. Int J Emerg Med 2013; 6:19. [PMID: 23787072 PMCID: PMC3704912 DOI: 10.1186/1865-1380-6-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 06/01/2013] [Indexed: 11/13/2022] Open
Abstract
Since 2008, training for emergency physicians (EPs) in the Netherlands has been based on a national 3-year curriculum. However, it has become increasingly evident that it needs to expand beyond its initial foundations. The training period does not comply with European regulations of a minimum of 5 years. Adjusting to this European standard is a logical step. Experience with the 3-year Dutch training scheme has led to the general conclusion that this training period is too short. Recommendations for essential changes and the basis for their development are presented.
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Affiliation(s)
- Menno I Gaakeer
- Netherlands Society of Emergency Physicians, UMC Utrecht, Utrecht, The Netherlands
| | - Crispijn L van den Brand
- Netherlands Society of Emergency Physicians, Medisch Centrum Haaglanden, The Hague, The Netherlands
| | | | - Joris M van Lieshout
- Emergency Medicine Department, Admiraal De Ruyter Hospital, Goes en Vlissingen, The Netherlands
| | - Peter Patka
- Emergency Medicine, Erasmus MC, Rotterdam, The Netherlands
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26
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van Gemert JP, de Vree LM, Hessels RAPA, Gaakeer MI. Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature. Int J Emerg Med 2012; 5:45. [PMID: 23273401 PMCID: PMC3545847 DOI: 10.1186/1865-1380-5-45] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 11/20/2012] [Indexed: 11/10/2022] Open
Abstract
Patellar dislocations are a common injury in the emergency department. The conservative management consists of immobilisation with a cylinder cast, posterior splint or removable knee brace. No consensus seems to exist on the most appropriate means of conservative treatment or the duration of immobilisation. Therefore the aims of this review were first to examine whether immobilisation with a cylinder cast causes less redislocation and joint movement restriction than a knee brace or posterior splint and second to compare the redislocation rates after conservative treatment with surgical treatment. A systematic search of Pubmed, Embase and the Cochrane Library was performed. We identified 470 articles. After applying the exclusion and inclusion criteria, only one relevant study comparing conservative treatment with a cylinder cast, brace and posterior splint remained (Mäenpää et al.). In this study, the redislocation frequency per follow-up year was significant higher in the brace group (0.29; p < 0.05) than in the cylinder cast group (0.12) and the posterior splint group (0.08). The proportion of loss of flexion and extension was the highest in the cylinder cast group and the lowest in the posterior splint group (not significant). The evidence level remained low because of the small study population, difference in duration of immobilisation between groups and use of old braces. Also, 12 studies comparing surgical with conservative treatment were assessed. Only one study reported significantly different redislocation rates after surgical treatment. In conclusion, a posterior splint might be the best therapeutic option because of the low redislocation rates and knee joint restrictions. However, this recommendation is based on only one study with significant limitations. Further investigation with modern braces and standardisation of immobilisation time is needed to find the most appropriate conservative treatment for patellar luxation. Furthermore, there is insufficient evidence to confirm the added value of surgical management.
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Affiliation(s)
- Johanna P van Gemert
- Department of Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
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27
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Gaakeer MI, Veugelers R, Houser CM, Berben SAA, Bierens JJLM. [Acute pain at the emergency department: better treatment required]. Ned Tijdschr Geneeskd 2011; 155:A2241. [PMID: 21262007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Acute pain is common among patients at the emergency department and is still not being treated adequately. Repeated measurement and documentation of pain is essential for adequate pain treatment. The patient determines how much analgesia is needed. Pharmacological pain relief should not be delayed during the diagnostic process, not even in cases of abdominal pain. Opioids play a central role in the treatment of acute pain. Opiophobia is not justified. Adequate pain relief started at the emergency department must be continued throughout both hospital admission and discharge to home.
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Affiliation(s)
- Menno I Gaakeer
- Medisch Spectrum Twente, afd. Spoedeisende Geneeskunde, Enschede, the Netherlands.
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28
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Gaakeer MI, Dijkhuis CM. [Diagnostic image (364). A boy with a painful inguinal mass]. Ned Tijdschr Geneeskd 2008; 152:556. [PMID: 18402321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A 9-year-old boy presented with right-sided abdominal pain and an inguinal mass due to torsion of an acquired ectopic testicle.
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Affiliation(s)
- M I Gaakeer
- Oosterscheldeziekenhuis, afd. Heelkunde, Goes.
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29
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Van Rossum AM, Gaakeer MI, Verweel S, Hartwig NG, Wolfs TF, Geelen SP, Lamberts SW, de Groot R. Endocrinologic and immunologic factors associated with recovery of growth in children with human immunodeficiency virus type 1 infection treated with protease inhibitors. Pediatr Infect Dis J 2003; 22:70-6. [PMID: 12544412 DOI: 10.1097/00006454-200301000-00017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Growth failure is a common presenting sign in children with HIV disease and is a sensitive indicator of disease progression in children with AIDS. Highly active antiretroviral therapy (HAART) is associated with a significant decrease in viral load and a subsequent rise in CD4+ T cell counts in HIV-1-infected children and also with increased height and weight. The underlying mechanisms of catch-up growth during HAART are yet unknown. METHODS Height and weight measurements, blood sample analyses for HIV-1 RNA and peripheral blood CD4+ T cell counts were obtained twice within 1 month before the start of HAART and after 12, 24, 36 and 48 weeks of treatment. Serum concentrations of insulin-like growth factor I (IGF-1), IGFs complexed to specific, structurally homologous binding proteins (IGFBP-3), cortisol, free thyroxine and tumor necrosis factor alpha (TNF-alpha) were measured before the start of therapy and after 24 weeks. In addition serum IGF-1 and IGFBP-3 values were determined after 48 weeks. RESULTS Twenty-seven HIV-1-infected children with a median age of 5.5 years (range, 0.3 to 14.9 years) were included. Overall no significant changes in height and body mass index (BMI) z scores were observed. The median baseline plasma viral load of 68,800 copies/ml decreased to less than the detection limit of 500 copies/ml in 80% of the children after 48 weeks. TNF-alpha values were elevated (44 pg/ml) at baseline and decreased significantly to 37 pg/ml after 24 weeks. At baseline elevated TNF-alpha was observed in 78%, which decreased to 55% after 24 weeks. Baseline free thyroxine and cortisol values were normal and did not change during therapy. Baseline serum of IGF-1 and IGFBP-3 concentrations were normal, but IGF-1 tended to be lower than IGFBP-3. Both values increased significantly after the initiation of therapy. IGFBP-3 decreased after 48 weeks whereas IGF-1 stabilized. The increase in IGF-1 was significantly higher in children in whom the BMI and length (after correction for age and sex) increased the most. CONCLUSION Hypothyroidism and adrenal axis abnormalities are not associated with restoration of growth after the initiation of antiretroviral therapy in HIV-1-infected children. The combination of relatively high serum IGFBP-3 concentration and relatively lower serum IGF-1 suggests the presence of a growth hormone-resistant state. During treatment with a protease inhibitor-containing regimen, decreased serum IGFBP-3 and stabilization of IGF-1 after a significant initial increase suggest restoration of normal sensitivity to growth hormone and recovery to an anabolic condition.
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Affiliation(s)
- Annemarie M Van Rossum
- Division of Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Erasmus MC/Sophia Children's Hospital, Rotterdam, the Netherlands
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