Clinical use of the manchester triage system in patients with dizziness - An observational study in the emergency department

INTRODUCTION

Dizziness is a common symptom with diverse causes, including ear-nose-throat, internal, neurological, or psychiatric origins. While for most parts treatable in nonemergency settings, it can also signal time-critical conditions, like an unnoticed stroke, requiring prompt diagnosis and treatment to prevent lasting harm or death. The aim of this study was to evaluate the validity of the Manchester Triage System in classifying patients presenting with dizziness based on final diagnoses and patient outcomes, as no specific flow chart exists for this symptom in the MTS.

METHODS

Monocentric, retrospective observational study. To test the validity of the MTS in the triage of dizziness patients, the treatment level was used as a surrogate parameter. We grouped the patients into outpatient, normal ward and intermediate care/intensive care unit (IMC/ICU) patients. Furthermore, we analyzed the dizziness patients in subgroups based on the origin of their dizziness to identify potential improvements for the MTS. Patients with dizziness and stroke, who represent the most vulnerable group of dizziness patients, were also evaluated separately.

RESULTS

During the observation period, 2958 patients presented at the ED with the symptom dizziness and 52 017 without, who formed the reference group. When examining the relationship between triage level and subsequent treatment level, a larger deviation is observed compared to the reference group. The receiver operating characteristics (ROC) regarding hospital admission in general showed an area under the curve (AUC) in the subgroup with dizziness due to a central nervous system causes (n=838) of 0.69 (95% CI 0.65 - 0.72) and in the subgroup of dizziness by other organic cause (n=901), an AUC of 0.64 (95% CI 0.60 - 0.68). The reference group had an AUC 0.75 (95% CI 0.75 - 0.76) here. In relation to admission to IMC/ICU, the results were similar. The sensitivity of the MTS in terms of an adequate initial assessment of dizziness patients with stroke or transient ischemic attack (TIA) was 0.39, the specificity was 0.91 (reference group sensitivity 0.72, specificity 0.82).

CONCLUSION

In terms of construct validity, the present study revealed that the use of MTS as a priority triage assessment tool was found to be less accurate in emergency patients with dizziness, particularly those diagnosed with stroke/TIA, when compared to other emergency patients.

Use of overactive bladder anticholinergic medications associated with falls leading to emergency department visits: results from the ADRED study

PURPOSE

Drug intake might be a modifiable factor for the individual fall-risk of older adults, and anticholinergic properties of drugs need to be considered. This study is aimed at analyzing the association of older adults' individual anticholinergic load with particular focus on use of overactive bladder anticholinergic medications with falls in multi-medicated patients.

MATERIALS AND METHODS

Cases of the prospective, observational, multi-center study on adverse drug reactions leading to emergency departments (ADRED study) between 2015 and 2018 in Germany were analyzed comparing the exposure of overactive bladder anticholinergic medications on the chance to present with a fall with patients without exposure. Logistic regression analysis was used adjusting for pre-existing conditions, drug exposure, and the individual anticholinergic burden by drug use. To this end, a combination of seven expert-based anticholinergic rating scales was used.

RESULTS

The anticholinergic burden was higher in patients with overactive bladder anticholinergic medications (median 2 [1; 3]) compared to not taking drugs of interest. Presenting with a fall was associated with overactive bladder anticholinergic medications (odds ratio (OR) 2.34 [95% confidence interval 1.14-4.82]). The use of fall-risk increasing drugs was likewise associated (OR 2.30 [1.32-4.00]). The anticholinergic burden itself seemed not to be associated with falls (OR 1.01 [0.90-1.12]).

CONCLUSIONS

Although falls occur multifactorial in older adults and confounding by indication cannot be ruled out, the indication for a drug treatment should be decided with caution when other, non-pharmacological treatment options have been tried.

GERMAN CLINICAL TRIAL REGISTER

DRKS-ID: DRKS00008979, registration date 01/11/2017.

Impaired humoral immunity to BQ.1.1 in convalescent and vaccinated patients

Determining SARS-CoV-2 immunity is critical to assess COVID-19 risk and the need for prevention and mitigation strategies. We measured SARS-CoV-2 Spike/Nucleocapsid seroprevalence and serum neutralizing activity against Wu01, BA.4/5 and BQ.1.1 in a convenience sample of 1,411 patients receiving medical treatment in the emergency departments of five university hospitals in North Rhine-Westphalia, Germany, in August/September 2022. 62% reported underlying medical conditions and 67.7% were vaccinated according to German COVID-19 vaccination recommendations (13.9% fully vaccinated, 54.3% one booster, 23.4% two boosters). We detected Spike-IgG in 95.6%, Nucleocapsid-IgG in 24.0%, and neutralization against Wu01, BA.4/5 and BQ.1.1 in 94.4%, 85.0%, and 73.8% of participants, respectively. Neutralization against BA.4/5 and BQ.1.1 was 5.6- and 23.4-fold lower compared to Wu01. Accuracy of S-IgG detection for determination of neutralizing activity against BQ.1.1 was reduced substantially. We explored previous vaccinations and infections as correlates of BQ.1.1 neutralization using multivariable and Bayesian network analyses. Given a rather moderate adherence to COVID-19 vaccination recommendations, this analysis highlights the need to improve vaccine-uptake to reduce the COVID-19 risk of immune evasive variants. The study was registered as clinical trial (DRKS00029414).

Der Übergabeprozess in der zentralen Notaufnahme – Konsentierung von Inhalten im Rahmen eines Delphi-Verfahrens

Hintergrund und Ziel der Arbeit

Für die Übergabe in der Notaufnahme – der Nahtstelle von prähospitaler zu klinischer Versorgung – stellen Merkhilfen („mnemonics“) das „Rückgrat“ für eine strukturierte Übermittlung von relevanten Informationen dar. In Deutschland existiert bis zum heutigen Tag keine Standardisierung bzw. konkrete Vorgabe, welche Merkhilfe zur Übergabe genutzt werden soll. Die vorliegende Untersuchung definiert erstmalig anhand eines strukturierten und mehrstufigen Konsentierungsprozesses (Delphi-Verfahren) von Experten (Mandatsträgern), welche Übergabeinhalte für erforderlich gehalten werden. Ziel dabei ist die Schaffung einer Grundlage zur Entwicklung einer bundeseinheitlichen Merkhilfe.

Methodik

Durchgeführt wurde ein Delphi-Verfahren, welches sich an den Regularien der Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften e. V. (AWMF) orientiert.

Ergebnisse

Im Rahmen des durchgeführten Delphi-Verfahrens konnte neben konkreten Inhalten der Merkhilfe auch deren Reihenfolge festgelegt werden. Übergabeinhalte wurden zu den Punkten Crew Resource Management (CRM) und Patientenidentifikation, Beschreibung der Notfallsituation, Notfallpriorität (ABCDE-Schema) und Vitalparameter, durchgeführte Maßnahmen, Anamnese, Zusammenfassung mit der Möglichkeit für Rückfragen durch das übernehmende Team sowie Zeitdauer definiert.

Diskussion

Die Ergebnisse der Arbeit bilden die evidenzbasierte Grundlage für die Entwicklung einer konkreten Merkhilfe („mnemonic“). Weitere Untersuchungen sollten sich nach Entwicklung einer geeigneten Merkhilfe darauf fokussieren, diese im Rahmen einer (prä-)klinischen Anwendungsstudie auf Praxistauglichkeit zu testen. Gleichzeitig sollte ein entsprechendes Schulungskonzept ausgearbeitet werden. Langfristig wird als Ziel eine bundesweit einheitliche Einführung angestrebt.

Aneurysmal Subarachnoid Hemorrhage during the Shutdown for COVID-19

The aim was to evaluate hospitalization rates for aneurysmal subarachnoid hemorrhage (SAH) within an interdisciplinary multicenter neurovascular network (NVN) during the shutdown for the COVID-19 pandemic along with its modifiable risk factors. In this multicenter study, admission rates for SAH were compared for the period of the shutdown for the COVID-19 pandemic in Germany (calendar weeks (cw) 12 to 16, 2020), the periods before (cw 6–11) and after the shutdown (cw 17–21 and 22–26, 2020), as well as with the corresponding cw in the years 2015–2019. Data on all-cause and pre-hospital mortality within the area of the NVN were retrieved from the Department of Health, and the responsible emergency medical services. Data on known triggers for systemic inflammation, e.g., respiratory viruses and air pollution, were analyzed. Hospitalizations for SAH decreased during the shutdown period to one-tenth within the multicenter NVN. There was a substantial decrease in acute respiratory illness rates, and of air pollution during the shutdown period. The implementation of public health measures, e.g., contact restrictions and increased personal hygiene during the shutdown, might positively influence modifiable risk factors, e.g., systemic inflammation, leading to a decrease in the incidence of SAH.

[Primary assessment in the emergency department]

First goal in an emergency department must be the immediate recognition of patients at risk. The primary success of therapy depends mainly on whether a critical risk is identified immediately upon arrival at the central emergency department and appropriate therapy is initiated. In order to identify critical patients among the many patients with a wide range of diseases and, nurse-assisted initial assessment systems can help. The assessment thus represents a complex decision-making process to identify critically ill patients in times of high patient volume and limited resources.

Prospective Observational Multisite Study of Handover in the Emergency Department: Theory versus Practice

Introduction

The handover process in the emergency department (ED) is relevant for patient outcomes and lays the foundation for adequate patient care. The aim of this study was to examine the current prehospital to ED handover practice with regard to content, structure, and scope.

Methods

We carried out a prospective, multicenter observational study using a specifically developed checklist. The steps of the handover process in the ED were documented in relation to qualification of the emergency medical services (EMS) staff, disease severity, injury patterns, and treatment priority.

Results

We documented and evaluated 721 handovers based on the checklist. According to ISBAR (Identification, Situation, Background, Assessment, Recommendation), MIST (Mechanism, Injuries, Signs/Symptoms, Treatment), and BAUM (Situation [German: Bestand], Anamnesis, Examination [German: Untersuchung], Measures), almost all handovers showed a deficit in structure and scope (99.4%). The age of the patient was reported 339 times (47.0%) at the time of handover. The time of the emergency onset was reported in 272 cases (37.7%). The following vital signs were transferred more frequently for resuscitation room patients than for treatment room patients: blood pressure (BP)/(all comparisons p < 0.05), heart rate (HR), oxygen saturation (SpO₂) and Glasgow Coma Scale (GCS). Physicians transmitted these vital signs more frequently than paramedics BP, HR, SpO₂, and GCS. A handover with a complete ABCDE algorithm (Airway, Breathing, Circulation, Disability, Environment/Exposure) took place only 31 times (4.3%). There was a significant difference between the occupational groups (p < 0.05).

Conclusion

Despite many studies on handover standardization, there is a remarkable inconsistency in the transfer of information. A “hand-off bundle” must be created to standardize the handover process, consisting of a uniform mnemonic accompanied by education of staff, training, and an audit process.

The phenotype of adverse drug effects: Do emergency visits due to adverse drug reactions look different in older people? Results from the ADRED study

AIMS

Older patients in particular suffer from adverse drug reactions (ADR) when presenting in the emergency department. We aimed to characterise the phenotype of those ADRs, to be able to recognise an ADR in older patients.

METHODS

Cases of ADRs in emergency departments collected within the multicentre prospective observational study (ADRED) were analysed (n = 2215). We analysed ADR-associated diagnoses, symptoms and their risk profiles. We present frequencies and odds ratios (OR) with 95% confidence intervals for adults (18-64 years) compared to older adults (≥65 years; young-old 65-79, old-old ≥80 years) and regression coefficients (B) for each year of age.

RESULTS

Most prominent differences were seen for drug-associated confusion, dehydration, and bradycardia (OR 6.70 [1.59-28.27], B .054; OR 6.02 [2.41-15.03], B .081, and 4.82 [2.21-10.54], B .040), more likely seen in older adults. Bleedings were reported in all age groups, but gastrointestinal bleedings occurred with more than doubled chance in older adults (OR 2.46 [1.77-3.41], B .030), likewise did other bleedings such as haemorrhage from respiratory passages (OR 2.89 [1.37-6.11], B.036). Falls were more likely in older adults (OR 2.84 [1.77-4.53], B .030), while dizziness was frequent in both age groups.

CONCLUSION

Our data point to differences in symptoms of ADRs between adults and older individuals, with dangerous drug-associated phenomena in the older adult such as bleedings or falls. Physicians should consider drug-associated origins of symptoms in older adults with an increased risk for serious health problems.

Adverse Drug Reactions in the Emergency Department: Is There a Role for Pharmacogenomic Profiles at Risk?-Results from the ADRED Study

Individual differences in required drug dosages exist based on the pharmacogenomic (PGx) profiles. This study aimed to assess associations between PGx profiles and adverse drug reactions (ADR) that lead to admissions to the emergency department (ED). ADR cases of the prospective multi-center observational trial in EDs (ADRED study) were analyzed (n = 776) together with the relevant PGx phenotypes of the enzymes CYP2D6, CYP2C19, CYP2C9, and VKORC1. Overall, the allele frequency distribution in this cohort did not differ from the population frequencies. We compared the frequencies of phenotypes in the subgroups with the drugs suspected of certain ADR, in the remaining cases. The frequency distribution of CYP2C19 differed for the ADR bleeding cases suspected of clopidogrel (p = 0.020). In a logistic regression analysis, higher CYP2C19 activity (OR (95% CI): 4.97 (1.73−14.27)), together with age (1.05 (1.02−1.08)), showed an impact on the clopidogrel-suspecting ADRs, when adjusting for the clinical parameters. There was a trend for an association of phenprocoumon-risk profiles (low VKORC1 or CYP2C9 activity) with phenprocoumon-suspecting ADRs (p = 0.052). The PGx impact on serious ADRs might be highest in drugs that cannot be easily monitored or those that do not provoke mild ADR symptoms very quickly. Therefore, patients that require the intake of those drugs with PGx variability such as clopidogrel, might benefit from PGx testing.

[Recommendations for emergency management of patients with permanent mechanical circulatory support : Consensus statement of DGTHG, DIVI, DGIIN, DGAI, DGINA, DGfK and DGK]

The prevalence of patients living with long-term mechanical circulatory support (MCS) is rapidly increasing due to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. Patients with long-term MCS are very likely to require emergency medical support due to MCS-associated complications (e.g., right heart failure, left ventricular assist device malfunction, hemorrhage and pump thrombosis) but also due to non-MCS-associated conditions. Because of the unique characteristics of mechanical support, management of these patients is complicated and there is very little literature on emergency care for these patients. The purpose of this national scientific statement is to present consensus-based recommendations for the initial evaluation and resuscitation of adult patients with long-term MCS.

Adverse Drug Reactions (ADR) and Emergencies

BACKGROUND

Adverse drug reactions (ADR) are a common reason for emergency room visits and for hospitalization. An ADR is said to have occurred when the patient's symptoms and signs are considered to be possibly, probably, or definitely related to the intake of a drug.

METHODS

In four large hospital emergency departments, one in each of four German cities ( Ulm, Fürth, Bonn, and Stuttgart), the percentage of suspected ADR cases among all patients presenting to the emergency room was determined during a 30-day period of observation. ADRs were ascertained by screening the digital records of all patients seen in the emergency room; causality was assessed as specified by the WHO-UMC (Uppsala Monitoring Center).

RESULTS

ADR were sought in a total of 10 174 emergency department visits. 665 cases of suspected ADR were found, yielding a prevalence of 6.5%. The prevalence of ADR among patients with documented drug intake was 11.6%. Among the patients with documented suspected ADRs, 89% were hospitalized (in contrast to the 43.7% hospitalization rate in the entire group of 10 174 emergency department visits). A possible causal relationship between the patient's symptoms and signs and the intake of a drug was found in 74-84% of cases. Patients with ADR were found to be taking a median of 7 different drugs simultaneously.

CONCLUSION

Adverse drug reactions are a relevant cause of emergency department visits, accounting for 6.5% of the total visits in this study, and often lead to hospital admission. The ADRED (Adverse Drug Reactions in Emergency Departments) study, which is now being conducted, is intended to shed further light on their causes, patient risk factors, and potential avoidability.

Validity of the Manchester Triage System in emergency patients receiving life-saving intervention or acute medical treatment-A prospective observational study in the emergency department

RATIONALE, AIMS, AND OBJECTIVES

The spectrum of cases seen by emergency departments ranges from minor illnesses or injuries to complex diseases with high mortality. Some patients require life-saving interventions (LSIs) or therapeutic treatment for an acute illness to prevent an expected imminent life-threatening condition immediately upon arrival. No published study has evaluated the validity of the Manchester Triage System (MTS) in the context of immediate LSI or acute emergency treatment (AET).

METHODS

The definition of LSI was based on a literature search. AET was defined by an expert panel based on current emergency guidelines and diagnostic guideline recommendations. In a 4-month observation period, an independent external observer documented all executed LSIs or AETs using a checklist. Sensitivity, negative predictive value, likelihood ratio negative (LR-), and accuracy of MTS triage level for the identification of patients receiving an LSI or AET were calculated.

RESULTS

In 1762 patients, 40 (2.3%) LSIs and 89 (5.1%) AETs were observed. In the LSI group, sensitivity of MTS was 75.0%, negative predictive value (NPV) was 99.2% (95% CI: 98.7%-99.6%), LR- was 0.303 (95% CI: 0.189-0.487) and accuracy (ACC) was 98.5% (95% CI: 97.8%-98.9%). In the AET group, sensitivity was 82.0%, NPV was 98.9% (95% CI: 98.1%-99.3%), LR- was 0.206 (95% CI: 0.132-0.322), and ACC was 86.5% (95% CI: 84.9%-88.1%).

CONCLUSION

The MTS is a valid instrument for a first assessment of emergency patients in critical condition upon arrival.

Management and outcome of epistaxis under direct oral anticoagulants: a comparison with warfarin

BACKGROUND

Epistaxis is one of the more common reasons for emergency room visits. The main risk factor for epistaxis is anticoagulant therapy. Until recently, the main culprit was oral intake of a vitamin K antagonist, such as warfarin, which has a number of side effects. Even more recently, several direct oral anticoagulants, rivaroxaban and dabigatran, have been approved for use. We investigated the possible differences between treatment of epistaxis with direct oral anticoagulants and vitamin K antagonists.

METHODS

We conducted a retrospective cohort study at a tertiary referral center in Germany. All patients who were admitted within a 1-year period were included. Patient files were used to obtain the information.

RESULTS

Overall, 677 patients were included in our study. Of these, 159 had been treated with vitamin K antagonists and 49 with direct oral anticoagulants. There were no significant differences in terms of age (p = 0.592), sex (p = 0.372), vital signs, bloodwork, or location of bleeding (p = 0.372). Management of epistaxis between the groups was also comparable (p = 0.399), with similar hospital admission rates (37.1% vs 24.5%; p = 0.145) and duration of stay (3.5 ± 2.1 days vs 3.8 ± 3.3 days; p = 0.650).

CONCLUSION

We found no evidence to suggest epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants. A significant proportion of patients on vitamin K antagonists were not within the target range for international normalized ratio, highlighting one of the main issues with oral anticoagulation by vitamin K antagonists.

[Acute Gout in Emergency Admissions - Patient Characteristics and Adherence of Care Processes to Current Guidelines]

BACKGROUND

Gout or hyperuricemia are both well known and common diseases. The prevalence of gout is increasing worldwide. Thus, patients with gout are becoming more common. Although there are several published guidelines for the management of gout, actual treatment of gout is inconsistent with these guidelines in many respects. Gout is usually treated by general practitioners (GP) in Germany. The aim of our study was to show which patients present to the emergency department and to record how treatment and clinical diagnostic testing of gout patients is performed in the emergency department of a university hospital in Germany. No such data have been published for Germany.

METHOD

Retrospective analysis of data of patients with ICD Code M10.xx from the emergency department at a university hospital from 05/2013 until 04/2016.

RESULTS

65 patients were treated with acute gout during the study period at the emergency department (age ∅ 53.45 y, 76.9% male, 23.07% female). 42 patients (65%) came outside normal office hours of GPs. In 31 patients, hyperuricemia or gout was known in their medical history, in 22 of these acute gout was known. 48 (73%) of patients came with monoarthritis and therefrom 40 with "classic" gout, such as podagra. 57 (86%) patients were subjected to diagnostic blood analysis and 31 (48%) diagnostic X-ray of the affected joint. We defined the appropriate indications for X-ray in diagnosis of acute gout as: signs of superinfection, prior surgical intervention or uncertain trauma in case history. According to this definition, 67% of the X-rays were performed without the correct indication. Four Patients were given punction of the affected joint to demonstrate monosodium urate monohydrate (MSU) crystals. Twelve patients were admitted as inpatients for surgery and/or antibiotic treatment. 51 (78%) patients received NSAIDs, 7 in combination with steroids and 4 patients received colchicine. Of those patients who received NSAID, 17 had an unknown or impaired renal function. Seven patients received neither pharmacological treatment nor recommendations for further treatment. Ten patients (15%) received a urate-lowering therapy or an existing therapy was increased during acute gout. In 10 patients, a urate-lowering therapy was recommended as further therapy. 63% were given further treatment recommendations such as cryotherapy or diet.

CONCLUSIONS

Acute gout is seldom presented in the emergency room (< 1‰). This confirms the impression that gout is mainly a disease treated in the outpatient setting. As shown in our study, the pharmacological treatment of acute gout was largely consistent with the guideline recommendations; nevertheless observance of renal function before treatment with NSAIDs should be emphasised. Furthermore, we identified overuse of diagnostic procedures. Current guidelines recommend diagnosing acute gout with clinical scores. In conclusion, our study shows that those clinical diagnostic scores should be implemented in clinical practice, in order to avoid unnecessary diagnostic procedures.

Improvement of polytrauma management-quality inspection of a newly introduced course concept

RATIONALE, AIMS, AND OBJECTIVES

A systematic literature search for training course concepts for care of severely injured and severely ill patients respecting improvement of process and outcome yielded little data. For several years, the University Hospital of Bonn has hosted a shock-room management course which, on the one hand, communicates human factor aspects and, on the other hand, pursues interdisciplinary and interprofessional team training. The Bonn shock-room management course (BSM-course®) differs from other courses in both format and principles. The aim of this study was to evaluate the quality of the structure of the course based on course evaluations of participants and its impact on the quality of the process and results for polytrauma care.

METHODS

Single-center retrospective evaluation study (2011 to 2014). It was based on data from simulator training and records from the German Trauma Registry (DGU)®.

RESULTS

Subjective evaluation of participants (n = 188) of the structure quality of Bonn's shock-room management course was overall positive. Objective measures of course participant performance also improved during simulation training (P = 0.012). An increasing number of trained employees also had a positive influence in reducing process time for shock-room care. Further, the course likewise had a positive impact on documentation quality (degree of completion), with regard to 4 relevant predictive parameters. Early mortality during the first 24 hours remained constant at 6.0-6.5% between 2011 and 2013, yet it decreased to 3.1% in 2014.

CONCLUSION

The BSM-course® represents a symbiosis of horizontal team approach of trauma care and human factor training. The course format is able to ensure interdisciplinary and interprofessional team training with a high degree of efficiency. Furthermore, the presented work shows that a modern course concept can improve the quality of trauma care.

[Neglected, lonely and sick - the social breakdown : A special patient group in the emergency department]

BACKGROUND

The emergency department (ED) is increasingly becoming the primary care unit of patients who are no longer able to meet the necessary minimum requirements for a healthy life. In the emergency medical care of these patients, fixation errors and stereotyped thinking can distract from serious illnesses, which can be tended by emergency medicine. This group of patients, with their multifactorial problems, represents a special challenge for the staff of the ED. The aim of this study is to improve the quality of the care for a special patient group.

MATERIALS AND METHODS

A monocentric retrospective observation study was conducted at the University Hospital Bonn (UKB). On the basis of case studies, the emergency medical care of this special patient group was examined in the ED.

RESULTS

Over the period of 7 years (2009 to 2016), 17 patients in a state of total neglect could be examined. The endpoints identified, during the emergency care, are the therapy of life-threatening diseases, laboratory pathologies, introduction of infectious protective measures, initiation of diagnostic measures, measures to be initiated within different departments (operating room, intensive care unit) and outcome.

CONCLUSION

Patients in a state of total neglect require interdisciplinary primary care at a hospital with extended care structures. The apparent primary impression of these patients must not lead to a fixation error. Due to the often not obtainable history of the patient's and the complex appearance of these patients, the evaluation should be carried out according to a defined algorithm in the emergency room.

[Emergency departments--2016 update]

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

Subacute Subclinical Brain Infarctions after Transcatheter Aortic Valve Implantation Negatively Impact Cognitive Function in Long-Term Follow-Up

Aims

To date every post-procedural cerebrovascular embolic event (CVE) is dreaded for its potential to accelerate cognitive decline after transcatheter aortic valve implantation (TAVI). This study differentiates the impact of acute (procedural) and post-acute cerebrovascular embolic events (CVEs) on cognitive performance.

Methods

Magnetic resonance imaging (MRI) before, early and late after TAVI was performed to quantify embolic burden. Quantification of diffusion- and T1-weighted lesions, as well as white-matter and total brain volumes, as well as cognitive function testing (MMSE) were assessed in 28 patients with a medium follow-up period of 34 months.

Results

Procedural diffusion-weighted lesions were observed in 17 patients (61%), but demonstrated locoregional remnants only in a minority of patients in long-term follow-up (6.5%). Acute CVEs did not impact the trajectory of late silent brain infarctions (SBI), white-matter hyperintensities, and cerebral atrophy. Functionally, early CVEs did not affect cognitive function. In contrast, patients with “new” SBIs after TAVI had a trend to cognitive deterioration in long-term follow-up (“new”SBI: MMSE -1.4 / no “new”SBI: MMSE +1.5, p = 0.067). Interestingly, only a fraction of these “new” SBIs evolved from procedural CVEs (22.2%).

Conclusions

Aquired SBIs after TAVI, but not DW-CVE per se are associated with functional impairment long-term after TAVI. In the context of subacute thrombosis seen in TAVI prostheses, these findings set the stage for tailored stroke prevention and comprehensive surrogate endpoint definitions in neuroprotective trials.

Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment

BACKGROUND

The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS.

MATERIALS AND METHODS

This retrospective analysis included patients >16 presenting to an ED in Bonn, Germany, on the first 12 days of each month between June 2012 and March 2014. Patients were classified into one of three septic groups, or no sepsis. For those with sepsis, adequacy of acuity assignment was based on the criteria of the first consensus conference of the American College of Chest Physicians and Society of Critical Care Medicine, first published in 1992. Adequacy of prioritisation is expressed as sensitivity and likelihood ratio (LR-).

RESULTS

Among 20 836 patients evaluated, 801 (3.8%) were septic; of these, 581 (72.5%) had sepsis, 194 (24.2%) had severe sepsis and 26 (3.2%) had severe sepsis with circulation dysfunction. Patients who met the criteria for sepsis were correctly prioritised with a sensitivity of 70.4% (95% CI 66.5 to 74.0). The LR- was 0.628 (95% CI 0.564 to 0.698). Patients with severe sepsis were appropriately prioritised with a sensitivity of 84.5% (95% CI 78.1 to 89.4), and LR- was 0.330 (95% CI 0.243 to 0.450). In the group with severe sepsis and circulation dysfunction, sensitivity of MTS was 61.5% (95% CI 39.3 to 79.8), and LR- was 0.466 (95% CI 0.286 to 0.757).

CONCLUSIONS

The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

Nurse Staffing Calculation in the Emergency Department - Performance-Oriented Calculation Based on the Manchester Triage System at the University Hospital Bonn

Background

To date, there are no valid statistics regarding the number of full time staff necessary for nursing care in emergency departments in Europe.

Material and Methods

Staff requirement calculations were performed using state-of-the art procedures which take both fluctuating patient volume and individual staff shortfall rates into consideration. In a longitudinal observational study, the average nursing staff engagement time per patient was assessed for 503 patients. For this purpose, a full-time staffing calculation was estimated based on the five priority levels of the Manchester Triage System (MTS), taking into account specific workload fluctuations (50th-95th percentiles).

Results

Patients classified to the MTS category red (n = 35) required the most engagement time with an average of 97.93 min per patient. On weighted average, for orange MTS category patients (n = 118), nursing staff were required for 85.07 min, for patients in the yellow MTS category (n = 181), 40.95 min, while the two MTS categories with the least acute patients, green (n = 129) and blue (n = 40) required 23.18 min and 14.99 min engagement time per patient, respectively. Individual staff shortfall due to sick days and vacation time was 20.87% of the total working hours. When extrapolating this to 21,899 (2010) emergency patients, 67–123 emergency patients (50–95% percentile) per month can be seen by one nurse. The calculated full time staffing requirement depending on the percentiles was 14.8 to 27.1.

Conclusion

Performance-oriented staff planning offers an objective instrument for calculation of the full-time nursing staff required in emergency departments.

Effects of prehospital hypothermia on transfusion requirements and outcomes: a retrospective observatory trial

OBJECTIVES

Prehospital hypothermia is defined as a core temperature <36.0 °C and has been shown to be an independent risk factor for early death in patients with trauma. In a retrospective study, a possible correlation between the body temperature at the time of admission to the emergency room and subsequent in-hospital transfusion requirements and the in-hospital mortality rate was explored.

SETTING

This is a retrospective single-centre study at a primary care hospital in Germany.

PARTICIPANTS

15,895 patients were included in this study. Patients were classified by admission temperature and transfusion rate. Excluded were ambulant patients and patients with missing data.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome values were length of stay (LOS) in days, in-hospital mortality, the transferred amount of packed red blood cells (PRBCs), and admission to an intensive care unit. Secondary influencing variables were the patient's age and the Glasgow Coma Scale.

RESULTS

In 22.85% of the patients, hypothermia was documented. Hypothermic patients died earlier in the course of their hospital stay than non-hypothermic patients (p<0.001). The administration of 1-3 PRBC increased the LOS significantly (p<0.001) and transfused patients had an increased risk of death (p<0.001). Prehospital hypothermia could be an independent risk factor for mortality (adjusted OR 8.521; p=0.001) and increases the relative risk for transfusion by factor 2.0 (OR 2.007; p=0.002).

CONCLUSIONS

Low body temperature at hospital admission is associated with a higher risk of transfusion and death. Hence, a greater awareness of prehospital temperature management should be established.

[Hospital-based acute care of emergency patients: the importance of interdisciplinary teamwork]

BACKGROUND

The care of emergency patients with life-threatening injuries or diseases presents a special challenge to the treatment team. Good interdisciplinary cooperation is essential for fast, priority-oriented, and efficient emergency room management. Particularly in complex situations, such as trauma room care, so-called human factors largely determine the safety and performance of the individual as well as the team. Approximately 70 % of all adverse events stem from human factors rather than from a lack of medical expertise. It has been shown that 70-80 % of such incidents are preventable through special training.

OBJECTIVES

Established course concepts based on so-called ABCDE schemes are a good basis for creating algorithms for targeted therapy, yet they are not sufficient for the training of team-specific issues. For this, special course concepts are required, such as crew resource management, which is provided through simulator-based training scenarios. This includes task management, teamwork, decision-making, and communication. The knowledge of what needs to be done in a team under the adverse and complex conditions of a medical emergency must be gained by training based on realistic and effective measures.

CONCLUSION

Course concepts that are geared toward interdisciplinary and interprofessional team training optimize patient safety and care by supporting the nontechnical abilities of team members.

The German Version of the Manchester Triage System and its quality criteria--first assessment of validity and reliability

Background

The German Version of the Manchester Triage System (MTS) has found widespread use in EDs across German-speaking Europe. Studies about the quality criteria validity and reliability of the MTS currently only exist for the English-language version. Most importantly, the content of the German version differs from the English version with respect to presentation diagrams and change indicators, which have a significant impact on the category assigned. This investigation offers a preliminary assessment in terms of validity and inter-rater reliability of the German MTS.

Methods

Construct validity of assigned MTS level was assessed based on comparisons to hospitalization (general / intensive care), mortality, ED and hospital length of stay, level of prehospital care and number of invasive diagnostics. A sample of 45,469 patients was used. Inter-rater agreement between an expert and triage nurses (reliability) was calculated separately for a subset group of 167 emergency patients.

Results

For general hospital admission the area under the curve (AUC) of the receiver operating characteristic was 0.749; for admission to ICU it was 0.871. An examination of MTS-level and number of deceased patients showed that the higher the priority derived from MTS, the higher the number of deaths (p<0.0001 / χ² Test). There was a substantial difference in the 30-day survival among the 5 MTS categories (p<0.0001 / log-rank test).The AUC for the predict 30-day mortality was 0.613. Categories orange and red had the highest numbers of heart catheter and endoscopy. Category red and orange were mostly accompanied by an emergency physician, whereas categories blue and green were walk-in patients. Inter-rater agreement between expert triage nurses was almost perfect (κ = 0.954).

Conclusion

The German version of the MTS is a reliable and valid instrument for a first assessment of emergency patients in the emergency department.

[Interdisciplinary emergency departments : first experiences from the ENT and head and neck perspective]

BACKGROUND

Centralized emergency departments are becoming a major source of health care in Germany. In this study, we evaluated the importance for ENT health care.

METHODS

In a retrospective study, all ENT emergency patients between May and July 2011 were characterized by diagnosis, therapy, and urgency (measured using the Manchester Triage System [MTS]). General epidemiological data from the emergency department were recorded between 2009 and 2011.

RESULTS

Between 2009 and 2011, 50,699 patients were treated in the centralized emergency department of the University Hospital Bonn. A total of 15,658 (30.8%) needed ENT health care. During May 2011 to July 2011, ENT emergency patients had not only a wide variety of diseases but also a broad range of ages (0-98 years). Using the MTS, emergency patients (4% acute emergencies) were identified and urgency was determined prior to first contact with the physician.

CONCLUSION

ENT emergency care plays an important role for centralized emergency departments. Most of the patients have ENT diseases treatable as an outpatient in a single visit. MTS can be used to determine the appropriate level of urgency.

[Facial impalement in childhood : obtain an overview before actionism]

Facial impalement in childhood is very rare. In most cases, it is caused by accident. We present two young patients who suffered a facial impalement injury and were treated in the interdisciplinary emergency room of the University Hospital Bonn, Germany. The degree of injury could not be completely determined during the first examination. Serious complications could be excluded after examination via computed tomography (CT) and surgical exploration. The indication to use CT or magnetic resonance imaging in childhood has to be considered in order to obtain full and exact information about the extent of injury.

Image and diagnosis quality of X-ray image transmission via cell phone camera: a project study evaluating quality and reliability

Introduction

Developments in telemedicine have not produced any relevant benefits for orthopedics and trauma surgery to date. For the present project study, several parameters were examined during assessment of x-ray images, which had been photographed and transmitted via cell phone.

Materials and Methods

A total of 100 x-ray images of various body regions were photographed with a Nokia cell phone and transmitted via email or MMS. Next, the transmitted photographs were reviewed on a laptop computer by five medical specialists and assessed regarding quality and diagnosis.

Results

Due to their poor quality, the transmitted MMS images could not be evaluated and this path of transmission was therefore excluded. Mean size of transmitted x-ray email images was 394 kB (range: 265–590 kB, SD ±59), average transmission time was 3.29 min ±8 (CI 95%: 1.7–4.9). Applying a score from 1–10 (very poor - excellent), mean image quality was 5.8. In 83.2±4% (mean value ± SD) of cases (median 82; 80–89%), there was agreement between final diagnosis and assessment by the five medical experts who had received the images. However, there was a markedly low concurrence ratio in the thoracic area and in pediatric injuries.

Discussion

While the rate of accurate diagnosis and indication for surgery was high with a concurrence ratio of 83%, considerable differences existed between the assessed regions, with lowest values for thoracic images. Teleradiology is a cost-effective, rapid method which can be applied wherever wireless cell phone reception is available. In our opinion, this method is in principle suitable for clinical use, enabling the physician on duty to agree on appropriate measures with colleagues located elsewhere via x-ray image transmission on a cell phone.