Optimal timing for the Modified Early Warning Score for prediction of short-term critical illness in the acute care chain: a prospective observational study

INTRODUCTION

The Modified Early Warning Score (MEWS) is an effective tool to identify patients in the acute care chain who are likely to deteriorate. Although it is increasingly being implemented in the ED, the optimal moment to use the MEWS is unknown. This study aimed to determine at what moment in the acute care chain MEWS has the highest accuracy in predicting critical illness.

METHODS

Adult patients brought by ambulance to the ED at both locations of the Amsterdam UMC, a level 1 trauma centre, were prospectively included between 11 March and 28 October 2021. MEWS was calculated using vital parameters measured prehospital, at ED presentation, 1 hour and 3 hours thereafter, imputing for missing temperature and/or consciousness, as these values were expected not to deviate. Critical illness was defined as requiring intensive care unit admission, myocardial infarction or death within 72 hours after ED presentation. Accuracy in predicting critical illness was assessed using the area under the receiver operating characteristics curve (AUROC).

RESULTS

Of the 790 included patients, critical illness occurred in 90 (11.4%). MEWS based on vital parameters at ED presentation had the highest performance in predicting critical illness with an AUROC of 0.73 (95% CI 0.67 to 0.79) but did not significantly differ compared with other moments. Patients with an increasing MEWS over time are significantly more likely to become critical ill compared with patients with an improving MEWS.

CONCLUSION

The performance of MEWS is moderate in predicting critical illness using vital parameters measured surrounding ED admission. However, an increase of MEWS during ED admission is correlated with the development of critical illness. Therefore, early recognition of deteriorating patients at the ED may be achieved by frequent MEWS calculation. Further studies should investigate the effect of continuous monitoring of these patients at the ED.

Challenges and patient outcomes in chronic subdural haematoma at the level of a regional care system A multi-centre, mixed-methods study from the East of England

BACKGROUND

Chronic subdural haematoma (cSDH) is a common neurosurgical pathology affecting older patients with other health conditions. A significant proportion (up-to 90%) of referrals for surgery in neurosciences units (NSU) come from secondary care. However, the organisation of this care and the experience of patients repatriated to non-specialist centres are currently unclear.

OBJECTIVES

This study aimed to clarify patient outcome in non-specialist centres following NSU discharge for cSDH surgery and to understand key system challenges. The study was set within a representative neurosurgical care system in the east of England.

DESIGN AND METHODS

We performed a retrospective cohort analysis of patients referred for cSDH surgery. Alongside case record review, patient and staff experience were explored using surveys as well as an interactive c-design workshop. Challenges were identified from thematic analysis of survey responses and triangulated by focussed workshop discussions.

RESULTS

Data on 381 patients referred for cSDH surgery from six centres was reviewed. One hundred and fifty-six (41%) patients were repatriated following surgery. Sixty-one (39%) of those repatriated suffered an inpatient complication (new infection, troponin rise or renal injury) following NSU discharge, with 58 requiring institutional discharge or new care. Surveys for staff (n = 42) and patients (n = 209) identified that resourcing, communication, and inter-hospital distance posed care challenges. This was corroborated through workshop discussions with stakeholders from two institutions.

CONCLUSIONS

A significant amount of perioperative care for cSDH is delivered outside of specialist centres. Future improvement initiatives must recognise the system-wide nature of delivery and the challenges such an arrangement presents.

The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems

AIM

To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden.

METHODS

Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation.

RESULTS

In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes.

CONCLUSIONS

Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study

AIM

To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm.

METHODS

Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared.

RESULTS

In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm).

CONCLUSIONS

Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.

Performance of a prehospital HEART score in patients with possible myocardial infarction: a prospective evaluation

INTRODUCTION

The History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain.

METHODS

In a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days.

RESULTS

Between November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone.

CONCLUSIONS

A HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.

From Social Rejection to Welfare Oblivion: Health and Mental Health in Juvenile Justice in Brazil, Colombia and Spain

(1) Background: This study aims to examine and describe the policies of three Latin American countries: Colombia, Brazil, and Spain, and identify how they implement their support systems for health, mental health, mental health for children and adolescents, and juvenile justice systems that support judicial measures with treatment and/or therapeutic approaches specialized in mental health. (2) Methods: Google Scholar, Medline, and Scopus databases were searched to identify and synthesize of the literature. (3) Results: Three shared categories were extracted to construct the defining features of public policies on mental health care in juvenile justice: (i.) models of health and mental health care, (ii.) community-based child and adolescent mental health care, and (iii.) mental health care and treatment in juvenile justice. (4) Conclusions: Juvenile justice in these three countries lacks a specialized system to deal with this problem, nor have procedures been designed to specifically address these situations within the framework of children's rights.

Emergency department visits and emergency-to-inpatient admissions for abnormal uterine bleeding in the USA nationwide

BACKGROUND

Abnormal uterine bleeding (AUB) is a common but understudied gynaecological problem, and data are lacking on emergency department (ED) visits and associated ED-to-inpatient admissions for AUB. This project aims to further understanding of the burden of AUB on patients and the healthcare system by establishing the number and characteristics of women with AUB in the ED and evaluating predictors of AUB-related inpatient hospitalisation in the USA.

METHODS

This is a cross-sectional study of women presenting to the ED with non-malignant AUB in the 2016 US Nationwide Emergency Department Sample (NEDS). Clinical, demographic and hospital system factors were evaluated. χ² and Mann-Whitney tests were used to compare the proportion of visits with each characteristic, resulting in inpatient admission versus discharge from the ED. Multivariable logistic regression models were used to analyse predictors of AUB in the ED and of AUB-related hospitalisations.

RESULTS

There were 1.03 million AUB-related visits in the 2016 NEDS, of which 11.2% resulted in inpatient admission. Clinical as well as demographic and hospital system factors influenced ED disposition. Women with AUB tended to be of reproductive age, be underinsured, live in lower income and urban areas, and present to urban and public hospitals. However, older age, higher income, better insurance, presentation to private hospitals and rural residence predicted inpatient admission.

CONCLUSIONS

Our study highlights the ED as an essential place of care for women with AUB while also demonstrating the importance of access to outpatient gynaecology services as some AUB-related ED visits may be preventable with outpatient care. The significant demographic and hospital system differences, as well as expected clinical differences, between women with AUB admitted to inpatient and women discharged from the ED imply structural biases impacting AUB-related ED care and add to the deepening understanding of health disparities.

Understanding the Lives of Aboriginal and Torres Strait Islander Women with Traumatic Brain Injury from Family Violence in Australia: A Qualitative Study Protocol

Globally, there is growing recognition of the connection between violence and head injuries. At present, little qualitative research exists around how surviving this experience impacts everyday life for women, particularly Aboriginal and Torres Strait Islander women. This project aims to explore the nature and context of these women's lives including living with the injury and to identify their needs and priorities during recovery. This 3-year exploratory project is being conducted across three Australian jurisdictions (Queensland, Northern Territory, and New South Wales). Qualitative interviews and discussion groups will be conducted with four key groups: Aboriginal and Torres Strait Islander women (aged 18+) who have acquired a head injury through family violence; their family members and/or carers; and hospital staff as well as government and non-government service providers who work with women who have experienced family violence. Nominated staff within community-based service providers will support the promotion of the project to women who have acquired a head injury through family violence. Hospital staff and service providers will be recruited using purposive and snowball sampling. Transcripts and fieldnotes will be analysed using narrative and descriptive phenomenological approaches. Reflection and research knowledge exchange and translation will be undertaken through service provider workshops.

Performance of early warning and risk stratification scores versus clinical judgement in the acute setting: a systematic review

OBJECTIVE

Risk stratification is increasingly based on Early Warning Score (EWS)-based models, instead of clinical judgement. However, it is unknown how risk-stratification models and EWS perform as compared with the clinical judgement of treating acute healthcare providers. Therefore, we performed a systematic review of all available literature evaluating clinical judgement of healthcare providers to the use of risk-stratification models in predicting patients' clinical outcome.

METHODS

Studies comparing clinical judgement and risk-stratification models in predicting outcomes in adult patients presenting at the ED were eligible for inclusion. Outcomes included the need for intensive care unit (ICU) admission; severe adverse events; clinical deterioration and mortality. Risk of bias among the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool.

RESULTS

Six studies (6419 participants) were included of which 4 studies were judged to be at high risk of bias. Only descriptive analysis was performed as a meta-analysis was not possible due to few included studies and high clinical heterogeneity. The performance of clinical judgement and risk-stratification models were both moderate in predicting mortality, deterioration and need for ICU admission with area under the curves between 0.70 and 0.89. The performance of clinical judgement did not significantly differ from risk-stratification models in predicting mortality (n=2 studies) or deterioration (n=1 study). However, clinical judgement of healthcare providers was significantly better in predicting the need for ICU admission (n=2) and severe adverse events (n=1 study) as compared with risk-stratification models.

CONCLUSION

Based on limited existing data, clinical judgement has greater accuracy in predicting the need for ICU admission and the occurrence of severe adverse events compared with risk-stratification models in ED patients. However, performance is similar in predicting mortality and deterioration.

PROSPERO REGISTRATION NUMBER

CRD42020218893.

Balancing stability and change: Lessons on policy responsiveness and turbulence in the disability care sector

Care systems worldwide regularly undergo reforms and adjustments in the hope of system improvements. In many ways this can align with calls for governments to be more 'adaptive' and 'agile' to changing care demands. However, such continued adaptations can create turbulence for the care sectors in question. In this article, we examine the large-scale reform of the Australia National Disability Insurance Scheme and the impact of a series of adaptations on the disability care sector in Australia. We find that the disability sector in Australia is experiencing turbulence and a lack of clarity about the rules regarding the programme, resulting in increased administrative burden and financial pressures. Such turbulence has flow-on effects on the level of care that is able to be accessed by people with disability in Australia.

Modelling STEMI service delivery: a proof of concept study

BACKGROUND

Access to individual percutaneous coronary intervention (PCI) centres has traditionally been determined by historical referral patterns along arbitrarily defined geographic boundaries. We set out to produce predictive models of ST-elevation myocardial infarction (STEMI) demand and time-efficient access to PCI centres.

METHODS

Travel times from random addresses to PCI centres in Melbourne, Australia, were estimated using Google map application programming interface (API). Departures at 08:15 and 17:15 were compared with 23:00 to determine the effect of peak hour traffic congestion. Real-world ambulance travel times were compared with estimated travel times using Google map developer software. STEMI incidence per postcode was estimated by merging STEMI incidence per age group data with age group per postcode census data. PCI centre network configuration changes were assessed for their effect on hospital STEMI loading, catchment size, travel times and the number of STEMI cases within 30 min of a PCI centre.

RESULTS

Nearly 10% of STEMI cases travelled more than 30 min to a PCI centre, increasing to 20% by modelling the removal of large outer metropolitan PCI centres (p<0.05). A model of 7 PCI centres compared favourably to the current existing network of 11 PCI centres (p=0.18 (afternoon), p=0.5 (morning and night)). The intraclass correlation between estimated travel times and ambulance travel times was 0.82, p<0.001.

CONCLUSION

This paper provides a framework to integrate prehospital environmental variables, existing or altered healthcare resources and health statistics to objectively model STEMI demand and consequent access to PCI. Our methodology can be modified to incorporate other inputs to compute optimum healthcare efficiencies.

Potential impact of a novel pathway for suspected myocardial infarction utilising a new high-sensitivity cardiac troponin I assay

BACKGROUND

High-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay.

METHODS

This retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of <1%. cTnI elevation rates, diagnostic outcomes and ED disposition were also compared between pathways.

RESULTS

For the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%).

CONCLUSION

The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.

Systematic review of medical student willingness to volunteer and preparedness for pandemics and disasters

OBJECTIVE

This systematic review aimed to estimate the willingness of students to volunteer during a disaster, and how well-prepared medical students are for volunteering by assessing their knowledge and medical school curriculum of disaster and pandemic medicine.

RESULTS

A total of 37 studies met inclusion criteria including 11 168 medical students and 91 medical schools. 24 studies evaluated knowledge (64.9%), 16 evaluated volunteering (43.2%) and 5 evaluated medical school curricula (13.5%). Weighted mean willingness to volunteer during a disaster was 68.4% (SD=21.7%, range=26.7%-87.8%, n=2911), and there was a significant difference between those planning to volunteer and those who actually volunteered (p<0.0001). We identified a number of modifiable barriers which may contribute to this heterogeneity. Overall, knowledge of disasters was poor with a weighted mean of 48.9% (SD=15.1%, range=37.1%-87.0%, n=2985). 36.8% of 76 medical schools curricula included teaching on disasters. However, students only received minimal teaching (2-6 hours).

CONCLUSIONS

This study demonstrates that there is a large number of students who are willing to volunteer during pandemics. However, they are unlikely to be prepared for these roles as overall knowledge is poor, and this is likely due to minimal teaching on disasters at medical school. During the current COVID-19 pandemic and in future disasters, medical students may be required to volunteer as auxiliary staff. There is a need to develop infrastructure to facilitate this process as well as providing education and training to ensure students are adequately prepared to perform these roles safely.

Common Ophthalmic Preservatives in Soft Contact Lens Care Products: Benefits, Complications, and a Comparison to Non-Preserved Solutions

PURPOSE

Preservatives are essential for preventing contact lens (CL)-related microbial keratitis (MK). The purpose of this review is to summarize the current knowledge related to the use of common ophthalmic preservatives in CL care products with respect to both safety and efficacy.

METHODS

Manuscripts written in English were obtained by searching PubMed.gov with the term contact lens plus antimicrobial, benzalkonium chloride, biguanide, Aldox, polyquaternium, preservative, thimerosal, EDTA (ethylenediaminetetraacetic acid), chlorhexidine, or blister pack.

RESULTS

This review found that first-generation preservatives are no longer used in CL multipurpose solutions (MPS) due to their high levels of ocular toxicity. Modern, high-molecular-weight preservatives, including polyquaternium-1 (PQ-1) and biguanides (PHMB), are generally effective against bacteria, minimally effective against fungi, and not effective against Acanthamoeba. PQ-1 and PHMB are likely safe when used with CLs, but they may cause ocular adverse events, with roughly equal risk between the two preservatives. Some CL MPS contain both PQ-1 and PHMB, but no increased risk of adverse events has been reported when combining the two. Hydrogen-peroxide (H₂O₂) solutions are effective against all common ocular microbes, including Acanthamoeba, and they have been proven safe with proper compliance. Povidone-iodine (P-I) solutions are not currently commercially available in North America, but they have been shown in other countries to be safe and effective.

CONCLUSION

Patients should be monitored when using PQ-1 or PHMB-containing solutions since they have been associated with ocular adverse events. If events are detected, patients should be switched to an alternative solution. H₂O₂ or P-I solutions are preferred for any patient who may expose their CLs to water because they are the only solution categories effective against Acanthamoeba.

Location of out-of-hospital cardiac arrest and the awareness time interval: a nationwide observational study

AIMS

A short awareness time interval (ATI, time from witnessing the arrest to calling for help) and bystander cardiopulmonary resuscitation (CPR) are important factors affecting neurological recovery after out-of-hospital cardiac arrest (OHCA). This study investigated the association of the location of OHCA with the length of ATI and bystander CPR.

METHODS

This population-based observational study used the nationwide Korea OHCA database and included all adults with layperson-witnessed OHCA with presumed cardiac aetiology between 2013 and 2017. The exposure was the location of OHCA (public places, private housing and nursing facilities). The primary outcome was short ATI, defined as <4 min from witnessing to calling for emergency medical service (EMS). The secondary outcome was the frequency of provision of bystander CPR. Multivariable logistic regression analysis was performed to evaluate the association of location of OHCA with study outcomes.

RESULTS

Of 30 373 eligible OHCAs, 66.6% occurred in private housing, 24.0% occurred in public places and 9.4% occurred in nursing facilities. In 67.3% of the cases, EMS was activated within 4 min of collapse, most frequently in public places (public places 77.0%, private housing 64.2% and nursing facilities 64.8%; p<0.01). The overall rate of bystander CPR was 65.5% with highest in nursing facilities (77.0%), followed by public places (70.1%) and private housing 62.3%; p<0.01). Compared with public places, the adjusted ORs (AORs) (95% CIs) for a short ATI were 0.58 (0.54 to 0.62) in private housing and 0.62 (0.56 to 0.69) in nursing facilities. The AORs (95% CIs) for bystander CPR were 0.75 (0.71 to 0.80) in private housing and 1.57 (1.41 to 1.75) in nursing facilities.

CONCLUSION

OHCAs in private housing and nursing facilities were less likely to have immediate EMS activation after collapse than in public places. A public education is needed to increase the awareness of necessity of prompt EMS activation.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary

OBJECTIVE

To develop comprehensive guidance that captures international impacts, causes and solutions related to emergency department (ED) crowding and access block.

METHODS

Emergency physicians representing 15 countries from all International Federation of Emergency Medicine (IFEM) regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020.

RESULTS

A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force.

CONCLUSIONS

The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

Validation of a new method for saliva cortisol testing to assess stress in first responders

BACKGROUND

Acute or chronic stress can lead to physical and mental disorders. Measuring cortisol can objectify the degree of stress. Cortisol is traditionally measured in serum, but recently the relevant fraction of free cortisol can be reliably measured in saliva, using the very sensitive liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The use of saliva is non-invasive and allows easy serial testing around stressful events. The main objective of this study is to investigate whether serial saliva cortisol determinations using the LC-MS/MS method can be used to assess the stress response that first responders may experience during moments of acute professional deployment in their daily work.

METHODS

Healthy first responders (police officers, firefighters, rapid response team, ambulance personnel, first aid and emergency medical personnel) were recruited to participate in a Euregional high-reliability simulation training ('Be Aware'-scenario training, 19 April 2018). At three time points, simultaneous venous blood samples and saliva samples were obtained. These time points were 1 hour before, immediately after and 10 hours after the simulation training. The correlation between changes in saliva cortisol measured by LC-MS/MS and serum cortisol at all three time points was determined. Results were compared with spectators not directly participating in the simulation.

RESULTS

70 subjects participated in the simulation. There was a strong correlation between the changes in saliva and blood cortisol at the three time points. A significant increase in blood and saliva cortisol was shown 1 hour after the experienced stress moments. The levels had almost completely returned to baseline in all healthy volunteers 10 hours later. Cortisol in spectators was unaffected.

CONCLUSION

Serial saliva cortisol measurements using LC-MS/MS is a reliable and fast non-invasive functional stress assay, which can be easily collected in daily practice and used for investigation and monitoring of stress response in front line responders.

Effect of hospital interventions to improve patient flow on emergency department clinical quality indicators

INTRODUCTION

The Royal College of Emergency Medicine highlights poor flow through hospitals as a major challenge to improving emergency department flow. We describe the effect of several hospital-wide flow interventions on Yeovil District Hospital's emergency department flow.

METHODS

During 2016, a design science research study addressed several areas disproportionally contributing to exit block within Yeovil District Hospital. In this follow-up study, we used a retrospective, before/after design, to describe the effect of these interventions on the ED. We used the Royal College of Emergency Medicine's clinical quality indicators (4-hour standard, time to decision-maker, 7-day unplanned reattendance, left without being seen, ambulatory patient care and patient experience). Pearson correlation coefficient (r) was used to compare variables. Wilcoxon signed-rank test was used to compare performance before and after the intervention.

RESULTS

Yeovil District Hospital emergency department was attended by 160 373 patients between August 2015 and October 2018. Mean monthly attendance was 4112 (±342) patients, mean age was 43 (±28) years with equal male/female split (49/51%). The 4-hour standard made a recovery from 92% to 97% (p=0.01) that did not correlate with a recovery in national data (r=0.09); this despite rising attendances both at Yeovil and nationally (r=0.75). All clinical quality indicators improved significantly (except unplanned reattendance and patient feedback which improved but not significantly).

DISCUSSION

The positive effect on emergency department clinical quality indicators reveals the beneficial impact of improving in-patient flow. Qualitative research is needed to better understand facilitators and barriers to flow improvement work. .

Computed tomography in patients with epileptic seizures admitted acutely to hospital: A population level analysis of routinely collected healthcare data

Approximately 1.4% of emergency medical admissions are due to epileptic seizures. For the majority of such cases, computed tomography (CT) will not inform acute management and is unnecessary.Pseudonymised, routinely collected data from seven hospitals within the Cheshire and Merseyside area of the UK were analysed. All patients with emergency admissions to hospital due to seizures between 2014 and 2017 were included. Use of CT of the head was identified from routine coding.We identified 4,183 individuals with an acute seizure admission, of which over 30% received a CT of the head. There was significant variation in CT among hospital trusts.The rate of CT for patients admitted with seizures is high and CT is not being directed to those where they may be indicated. Integrated care pathways and guidelines are required to improve the management of patients presenting acutely with seizures.

No rest for the weary: a cross-sectional study comparing patients' sleep in the emergency department to those on the ward

BACKGROUND

Boarding in emergency departments (EDs) is a persistent problem worldwide. We hypothesised that patients sleeping while being boarded in EDs have worse self-rated sleep than those admitted from EDs who sleep on the ward.

METHODS

Prospective cross-sectional study conducted at the University College Hospital, Galway between October and November 2016. Self-rated sleep in patients boarded in EDs from 23:00 to 07:00 was compared with those admitted to the ward before 23:00. Patients rated their sleep using the Richards-Campbell Sleep Questionnaire. Patients were excluded if they had cognitive impairment, were unable or incapacitated or had evidence of alcohol or drug use in the previous 24 hours. Continuous data are shown as medians (IQRs 25th-75th percentiles). Linear regression models of log-transformed outcome variables were performed.

RESULTS

Ninety-three patients were included and 22 were excluded. Patients who boarded in the ED were significantly more likely to be medical patients (78% vs 21%, p<0.001), to be older (median age (IQR)=60 (39-71) vs 47 (32-68), p=0.04) and have more urgent presentations (74% vs 48% presenting as Manchester triage category 1 or 2, p=0.01) than patients who sleep on a ward. Patients who slept on the ward had significantly better sleep scores (mean log-transformed sleep scores (SD)=2.92 (1.05) vs 3.72 (0.66), p<0.001)). Those sleeping in the ED reported greater noisiness than those sleeping on the ward (mean log-transformed noisiness scores (SD)=3.18 (1.10) vs 4.15 (0.57), p<0.001). These significant differences in sleep scores and noisiness ratings persisted after adjustment for age, triage category and admitting service.

CONCLUSION

We found those who sleep boarded in EDs have worse self-rated sleep than those who sleep on the ward.

Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units

Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.

Modelling attending physician productivity in the emergency department: a multicentre study

Objectives

Emergency physician productivity, often defined as new patients evaluated per hour, is essential to planning clinical operations. Prior research in this area considered this a static quantity; however, our group’s study of resident physicians demonstrated significant decreases in hourly productivity throughout shifts. We now examine attending physicians’ productivity to determine if it is also dynamic.

Methods

This is a retrospective cohort study, conducted from 2014 to 2016 across three community hospitals in the north-eastern USA, with different schedules and coverage. Timestamps of all patient encounters were automatically logged by the sites’ electronic health record. Generalised estimating equations were constructed to predict productivity in terms of new patients per shift hour.

Results

207 169 patients were seen by 64 physicians over 2 years, comprising 9822 physician shifts. Physicians saw an average of 15.0 (SD 4.7), 20.9 (SD 6.4) and 13.2 (SD 3.8) patients per shift at the three sites, with 2.97 (SD 0.22), 2.95 (SD 0.24) and 2.17 (SD 0.09) in the first hour. Across all sites, physicians saw significantly fewer new patients after the first hour, with more gradual decreases subsequently. Additional patient arrivals were associated with greater productivity; however, this attenuates substantially late in the shift. The presence of other physicians was also associated with slightly decreased productivity.

Conclusions

Physician productivity over a single shift follows a predictable pattern that decreases significantly on an hourly basis, even if there are new patients to be seen. Estimating productivity as a simple average substantially underestimates physicians’ capacity early in a shift and overestimates it later. This pattern of productivity should be factored into hospitals’ staffing plans, with shifts aligned to start with the greatest volumes of patient arrivals.

Differences in diagnostic process, treatment and social Support for Alzheimer's dementia between primary and specialist care: resultss from the Swedish Dementia Registry

Background

the increasing prevalence of Alzheimer's dementia (AD) has shifted the burden of management towards primary care (PC). Our aim is to compare diagnostic process and management of AD in PC and specialist care (SC).

Design

cross-sectional study.

Subjects

a total of, 9,625 patients diagnosed with AD registered 2011–14 in SveDem, the Swedish Dementia Registry.

Methods

descriptive statistics are shown. Odds ratios are presented for test performance and treatment in PC compared to SC, adjusted for age, sex, Mini-Mental State Examination (MMSE) and number of medication.

Results

a total of, 5,734 (60%) AD patients from SC and 3,891 (40%) from PC. In both, 64% of patients were women. PC patients were older (mean age 81 vs. 76; P < 0.001), had lower MMSE (median 21 vs. 22; P < 0.001) and more likely to receive home care (31% vs. 20%; P < 0.001) or day care (5% vs. 3%; P < 0.001). Fewer diagnostic tests were performed in PC and diagnostic time was shorter. Basic testing was less likely to be complete in PC. The greatest differences were found for neuroimaging (82% in PC vs. 98% in SC) and clock tests (84% vs. 93%). These differences remained statistically significant after adjusting for MMSE and demographic characteristics. PC patients received less antipsychotic medication and more anxiolytics and hypnotics, but there were no significant differences in use of cholinesterase inhibitors between PC and SC.

Conclusion

primary and specialist AD patients differ in background characteristics, and this can influence diagnostic work-up and treatment. PC excels in restriction of antipsychotic use. Use of head CT and clock test in PC are areas for improvement in Sweden.

Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems

BACKGROUND

In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system.

OBJECTIVE

The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting.

METHODS

We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach.

RESULTS

Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols.

CONCLUSIONS

Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.

Evolution of triage systems

The French word "trier", the origin of the word "triage", was originally applied to a process of sorting, probably around 1792, by Baron Dominique Jean Larrey, Surgeon in Chief to Napoleon's Imperial Guard. Larrey was credited with designing a flying ambulance: the Ambulance Volante. Baron Francois Percy also contributed to the organisation of a care system for the ongoing management of casualties. Out of the French Service de Santé, not only emerged the concept of triage, but the organisational structure necessary to handle the growing number of casualties in modern warfare.