| A new hope , |
| The European Society for Emergency Medicine is 25 years old: a moment of reflection No abstract available |
Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review The aim of this study was to systematically review the literature on the effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries. The review protocol was registered with PROSPERO and CINHAL, MEDLINE and EMBASE were searched for studies comparing nurse-initiated vs physician-initiated X-ray. Because of heterogeneity of patients, providers and outcomes, a meta-analysis was not performed. The 16 included studies were conducted between 1971 and 2018 and involved 8881 participants. There were four randomised trials and 12 observational studies that focussed on X-ray request accuracy (n = 14), emergency department processes (n = 6) and patient outcomes (n = 2). The quality of evidence for each outcome ranged from very low-to-moderate. Compared with physician-initiated X-ray, nurse-initiated X-ray uses no more resources, is safe and acceptable to patients. Nurse-initiated X-ray did not reduce time to X-ray or waiting time but in some studies, reduced emergency department length of stay and unplanned follow-up. |
Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection Objective The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. Patients and methods A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. Results Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). Conclusion The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality. |
Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection Objective After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d’urgence et de réanimation SMUR). Patients and methods This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of ‘death or ICU stay more than 72 h’. Results We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13–33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62–0.74). Conclusion In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample. |
Feasibility of continuous noninvasive arterial pressure monitoring in a prehospital setting, measurements during emergency transfer Objectives In severely injured or acutely ill patients close monitoring of blood pressure (BP) can be crucial. At the prehospital scene and during transfer to hospital, the BP is usually monitored using intermittent oscillometric measurements with an upper arm cuff every 3–5 min. The BP can be monitored noninvasively and continuously using the continuous noninvasive arterial pressure (CNAP) device. In this study, we investigated the feasibility of a CNAP device in a prehospital setting. Patients and methods The study was an observational convenience study. The CNAP device was applied to the patient once in the ambulance and measurements were carried out during transfer to hospital. The primary object was the number of patients in whom the CNAP device could monitor the BP continuously in a prehospital area en route to hospital. Results Fifty-nine patients were enrolled in this study. Fifty-four (92%) patients had their BP monitored continuously by the CNAP device. The main reasons for missing data were a mean BP below the detectable range, reduced pulse wave caused by constricted arteries in the fingers, or patients’ excessive movements. The CNAP device provided continuous measurements after a median of 164.5 s. No complications and no adverse events were observed. Conclusion Continuous measurement of the BP obtained by the CNAP device is feasible and safe in a prehospital setting under potentially difficult conditions. |
Drowning in fresh or salt water: respective influence on respiratory function in a matched cohort study Introduction For the most severe drowned patients, hypoxemia represents one of the major symptoms. As the influence of the type of water (fresh or salt water) on respiratory function is still unclear, the primary endpoint of this multicenter study was to compare hypoxemia according to the type of water. Methods Medical records of adult patients who experienced a drowning event and were consequently admitted to 10 ICU for acute respiratory failure were analyzed retrospectively using data collected over three consecutive summer periods. From an initial cohort of acute respiratory failure drowned patients, patients were matched by age, sex, Glasgow Coma Scale, and occurrence of cardiac arrest (yes or no). Results Among an initial cohort of 242 patients, 38 pairs were matched correctly. At the initial assessment, carried out upon ICU admission, hypoxemia was found to be deeper in the fresh water group (PaO2/FiO2: 141 ± 76 vs. 220 ± 122, P < 0.05). However, there was no significant difference in tissue oxygenation (assessed by blood lactate level) between groups. In terms of biology results, sodium levels were higher in the salt water group in the initial assessment (144 ± 6.8 vs. 140 ±5.2 mmol/l, P = 0.004), but no difference was observed later. No difference was recorded in the outcome or length of stay in ICU between groups. Conclusion Drowning in fresh water was associated with deeper hypoxemia in the initial assessment. Despite this initial difference, latter respiratory and biological parameters or outcome were similar in both groups. |
Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region Objective The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations. Patients and methods An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED. Results A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients. Conclusion Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion. |
Trend analysis of emergency department malpractice claims in the Netherlands: a retrospective cohort analysis Background Over the past two decades, several quality improvement projects have been implemented in emergency departments (EDs) in the Netherlands, one of these being the training and deployment of emergency physicians. In this study we aim to perform a trend analysis of ED quality of care in Dutch hospitals, as measured by the incidence of medical malpractice claims. Patients and methods We performed a multicentre retrospective cohort study of malpractice claims in five Dutch EDs over the period 1998–2014. Incidence risk ratios were calculated to demonstrate any relation of specific quality improvement initiatives with the primary outcome, defined as the number of claims per 10 000 ED visits per year. Results During the study period, the cumulative number of ED visits increased significantly from 99 145 in 1998 to 162 490 in 2014 (P < 0.01). In total, 228 of 2 348 417 ED visits (0.97 per 10 000) resulted in a malpractice claim. At the same time, the yearly number of ED claims filed decreased with 0.07 (0.03–0.10) per 10 000 each year. The claim rate was higher in the period before emergency physicians were employed in the ED [1.18 (0.98–1.41) claims per 10 000 visits] compared with the period after they were employed [0.81 (0.67–0.97), incidence risk ratio 0.69 (0.53–0.89), P < 0.01]. Conclusion Even though the number of ED visits increased significantly over the past two decades, the number of malpractice claims filed after an ED visit decreased. Various quality improvement initiatives, including the training and employment of emergency physicians, may have contributed to the observed decrease in claims. |
Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid Objectives Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG. Methods We undertook secondary analyses in three prospective diagnostic accuracy studies that included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded clinical features at the time of arrival using a bespoke form. Patients underwent serial troponin sampling and 30-day follow-up for the primary outcome of ACS. The model was derived by logistic regression in one cohort and validated in two similar prospective studies. Results The HE-MACS model was derived in 796 patients and validated in cohorts of 474 and 659 patients. HE-MACS incorporated age, sex, systolic blood pressure plus five historical variables to stratify patients into four risk groups. On validation, 5.5 and 12.1% (pooled total 9.4%) patients were identified as ‘very low risk’ (potential immediate rule out) with a pooled sensitivity of 99.5% (95% confidence interval: 97.1–100.0%). Conclusion Using only the patient’s history and ECG, HE-MACS could ‘rule out’ ACS in 9.4% of patients while effectively risk stratifying remaining patients. This is a very promising tool for triage in both the prehospital environment and ED. Its impact should be prospectively evaluated in those settings. |
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