Emergency Medicine

. Triage and assessment of injuries in early trauma care. Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.

The objective of this study was to determine if ED triage nurses could appropriately interpret the Ottawa Ankle Rules (OAR). We conducted a prospective, observational trial of a clinical decision rule in a suburban ED on a convenience sample of ED patients, aged >17 years with acute ankle injuries. Nurses and EPs were trained in the appropriate use of the OAR. Nurses and physicians recorded their initial blinded patient assessments on standardized data collection instruments that included the OAR. X-rays were ordered without specific discretion to OAR by nurses or physicians. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated as appropriate; kappa (k) values were calculated to assess interobserver agreement (IOA). One hundred three patients enrolled: mean age 37 ؎ 16 years; 67% female; 27 had fractures. IOA between nurses and physicians was moderate for overall interpretation of OAR (kappa ‫؍‬ 0.44). IOA (kappa) for each criterion varied from (1) moderate for fifth metatarsal pain (0.56), posterior malleolar pain (0.44), medial malleolar pain (0.40), and weight bearing with foot pain (0.48); to (2) fair for weight bearing with ankle pain (0.32) and navicular pain (0.21). Sensitivity of the nurse's interpretation of OAR for fracture was 92%, specificity 36%, negative predictive value 90%, and positive predictive value 32%. Sensitivity of the EP's utilization of the OAR for fracture was 92%, specificity 47% with a negative predictive value 94%, and a positive predictive value 38%. Nurses showed only a moderate ability to interpret the overall OAR for ordering of x-rays. Nurses' understanding of the individual criterion were variable. (Am J Emerg Med 2004;22:145-148.

Background: Despite the increasing global burden of stroke, there are limited data on stroke from Kenya to guide in decision-making. Stroke occurrence in sub-Saharan Africa has been associated with poor health outcomes. This study sought to establish the stroke incidence density and mortality in Kenya’s leading public tertiary hospitals for purposes of informing clinical practice and policy. Methods: This is a prospective study conducted at Kenya’s leading referral hospitals, namely, Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH). Adult patients with confirmed cases of stroke were recruited from February 2015 to January 2016 and followed up for a minimum period of 1 year. The WHO 2006 Stroke STEPS instrument was used to collect data on incidence and mortality at days 10 and 28 and every 3 months for 24 months. The person-time of follow-up was computed from admission to death, loss to follow-up, or the end of the study. A survival regression analysis w...

The objective of this study is to estimate the expected health outcomes, costs, cost-effectiveness of changing from Current Practice where thrombolytic therapy is given in hospital to Paramedic Practice where thrombolytic therapy is administered by appropriately trained paramedics (pre-hospital). A decision-analysis microsimulation model was constructed with a 30-day component and a long-term health state transition component. A brief review of the literature was undertaken to obtain data on time to needle to populate the model. The primary health outcome was quality-adjusted life years (QALYs); secondary outcomes included cardiac events, procedures, and survival. Costs to the Australian healthcare system for the rest of life were taken as the analytical perspective. On average, STEMI patients gain 0.13 QALYs at an additional life-time cost of $343. The incremental cost-effectiveness ratios were $3428 per life-year gained and $2601 per QALY gained. These estimates were robust to changes in a range of assumptions and parameter values. The most important factor was the time-to-needlethe greater the difference between Current Practice times and Paramedic Practice times, the greater the health benefits and lower the cost per QALY (and life-year) gained. A key factor in the model was the substantially lower incidence of heart failure from earlier time-to-needle. Importantly, there was little change in the cost per QALY gained for a wide range of ages; thus, there is no argument to limit thrombolysis by paramedics to above or below an age threshold. Paramedics administering thrombolysis can avert some STEMI deaths and the pre-hospital administration of thrombolysis is good value for money.

Background: Paramedic education has evolved in recent times from vocational post-employment to tertiary pre-employment supplemented by clinical placement. Simulation is advocated as a means of transferring learned skills to clinical practice. Sole reliance of simulation learning using mannequin-based models may not be sufficient to prepare students for variance in human anatomy. In 2012, we trialled the use of fresh frozen human cadavers to supplement undergraduate paramedic procedural skill training. The purpose of this study is to evaluate whether cadaveric training is an effective adjunct to mannequin simulation and clinical placement. Methods: A multi-method approach was adopted. The first step involved a Delphi methodology to formulate and validate the evaluation instrument. The instrument comprised of knowledge-based MCQs, Likert for self-evaluation of procedural skills and behaviours, and open answer. The second step involved a pre-post evaluation of the 2013 cadaveric training. Results: One hundred and fourteen students attended the workshop and 96 evaluations were included in the analysis, representing a return rate of 84%. There was statistically significant improved anatomical knowledge after the workshop. Students' self-rated confidence in performing procedural skills on real patients improved significantly after the workshop: inserting laryngeal mask (MD 0.667), oropharyngeal (MD 0.198) and nasopharyngeal (MD 0.600) airways, performing Bag-Valve-Mask (MD 0.379), double (MD 0.344) and triple (MD 0.326,) airway manoeuvre, doing 12-lead electrocardiography (MD 0.729), using laryngoscope (MD 0.726), using Magill W forceps to remove foreign body (MD 0.632), attempting thoracocentesis (MD 1.240), and putting on a traction splint (MD 0.865). The students commented that the workshop provided context to their theoretical knowledge and that they gained an appreciation of the differences in normal tissue variation. Following engagement in/ completion of the workshop, students were more aware of their own clinical and non-clinical competencies. The paramedic profession has evolved beyond patient transport with minimal intervention to providing comprehensive both emergency and non-emergency medical care. With limited availability of clinical placements for undergraduate paramedic training, there is an increasing demand on universities to provide suitable alternatives. Our findings suggested that cadaveric training using fresh frozen cadavers provides an effective adjunct to simulated learning and clinical placements.

The objective of this study is to estimate the expected health outcomes, costs, cost-effectiveness of changing from Current Practice where thrombolytic therapy is given in hospital to Paramedic Practice where thrombolytic therapy is administered by appropriately trained paramedics (pre-hospital). A decision-analysis microsimulation model was constructed with a 30-day component and a long-term health state transition component. A brief review of the literature was undertaken to obtain data on time to needle to populate the model. The primary health outcome was quality-adjusted life years (QALYs); secondary outcomes included cardiac events, procedures, and survival. Costs to the Australian healthcare system for the rest of life were taken as the analytical perspective. On average, STEMI patients gain 0.13 QALYs at an additional life-time cost of $343. The incremental cost-effectiveness ratios were $3428 per life-year gained and $2601 per QALY gained. These estimates were robust to changes in a range of assumptions and parameter values. The most important factor was the time-to-needlethe greater the difference between Current Practice times and Paramedic Practice times, the greater the health benefits and lower the cost per QALY (and life-year) gained. A key factor in the model was the substantially lower incidence of heart failure from earlier time-to-needle. Importantly, there was little change in the cost per QALY gained for a wide range of ages; thus, there is no argument to limit thrombolysis by paramedics to above or below an age threshold. Paramedics administering thrombolysis can avert some STEMI deaths and the pre-hospital administration of thrombolysis is good value for money.

Abstract: Background: Currently in Queensland, health information systems for ambulance services, emergency departments (EDs) and hospitals are not fully integrated. In medical emergency situations patients are often unable to give accurate demographic information, making the ...

Background Global epidemiological data regarding outcomes for patients in intensive care units (ICUs) are scarce, but are important in understanding the worldwide burden of critical illness. We, therefore, did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of ICU mortality. Methods 730 participating centres in 84 countries prospectively collected data on all adult (>16 years) patients admitted to their ICU between May 8 and May 18, 2012, except those admitted for fewer than 24 h for routine postoperative monitoring. Participation was voluntary. Data were collected daily for a maximum of 28 days in the ICU and patients were followed up for outcome data until death or hospital discharge. In-hospital death was analysed using multilevel logistic regression with three levels: patient, hospital, and country. Findings 10 069 patients were included from ICUs in Europe (5445 patients; 54•1%), Asia (1928; 19•2%), the Americas (1723; 17•1%), Oceania (439; 4•4%), the Middle East (393; 3•9%), and Africa (141; 1•4%). Overall, 2973 patients (29•5%) had sepsis on admission or during the ICU stay. ICU mortality rates were 16•2% (95% CI 15•5-16•9) across the whole population and 25•8% (24•2-27•4) in patients with sepsis. Hospital mortality rates were 22•4% (21•6-23•2) in the whole population and 35•3% (33•5-37•1) in patients with sepsis. Using a multilevel analysis, the unconditional model suggested signifi cant between-country variations (var=0•19, p=0•002) and betweenhospital variations (var=0•43, p<0•0001) in the individual risk of in-hospital death. There was a stepwise increase in the adjusted risk of in-hospital death according to decrease in global national income. Interpretation This large database highlights that sepsis remains a major health problem worldwide, associated with high mortality rates in all countries. Our fi ndings also show a signifi cant association between the risk of death and the global national income and suggest that ICU organisation has an important eff ect on risk of death. Funding None.

Background: Transition of care from Emergency Medical Services (EMS) to the Emergency Department (ED) represents an intersection at high risk for error. Minimal research has quantitatively examined data transfer at this point. In Pennsylvania, this handoff consists of a transfer-of-care form (TOC) provided by EMS to ED in addition to a verbal report. A prehospital patient care report (PCR) is later filed by EMS up to 72 hours after concluding care. Objective: To evaluate the congruence between prehospital records provided at handoff and the final PCR found in the patient's medical record. Our hypothesis was that there would be discrepancies between the TOC and final PCR. Methods: A retrospective chart review was conducted comparing the TOC from a single EMS agency to the final PCR found in the electronic medical record. A convenience sample of 200 patients who received advanced life support transport over a one-month period were included. Metrics to assess the discrepancy between the reports included chief complaint, allergies, medications, systolic and diastolic blood pressure (SBP and DBP), pulse, respiratory rate (RR), Glasgow Coma Score (GCS), and prehospital treatment provided. The level of agreement between the two sources was compared using kappa statistics and concordance correlation coefficients (CCC) with 95% confidence intervals. Results: Of the 200 encounters that met inclusion criteria, 72% had matching chief complaints between the TOC and PCR. Medications matched in 66% and allergies matched in 82%. Up to three BP, pulse, and RR readings were collected; only 30% of the third BP readings were available from the TOC, while 68% were available from the PCR. Comparing the three SBP values on the TOC to respective counterparts on the PCR showed a substantial correlation (all CCC >0.95). Pulse and DBP values had moderate-to-substantial correlation (CCC: 0.93, 0.94, 0.96 and 0.77, 0.92, 0.94 respectively). RR showed inconsistent correlation (CCC: 0.37, 0.84, 0.94). GCS showed a moderate correlation between the two forms (CCC: 0.81). Conclusion: There were significant differences between the information transferred to the ED through the TOC compared to what was recorded in the PCR. Further evaluation of the TOC process is needed to improve accuracy.

The addition of trauma to burn injuries may result in higher morbidity and mortality. The purpose of this study was to evaluate the outcomes of pediatric patients with a combination of burn and trauma injuries, and included all pediatric Burn only, Trauma only, and combined Burn-Trauma patients admitted between 2011 and 2020. Mean length of stay, ICU length of stay, and ventilator days were highest for the Burn-Trauma group. The odds of mortality were almost 13 times higher for the Burn-Trauma group when compared to the Burn only group (P = .1299). After using inverse probability of treatment weighting, the odds of mortality were almost 10 times higher for the Burn-Trauma group in comparison to the Burn only group (P < .0066). Thus, the addition of trauma to burn injuries was associated with increased odds of mortality, as well as longer ICU and overall hospital length of stay in this patient population.

Introduction Burn Intensive Care Units (BICU)s are resource-heavy and labor-intensive units with very sick patients. The removal of burns as a requirement from the surgical curriculum has decreased the number of rotating surgical trainees, but did not impact patient care needs. Our unit adopted an Advanced Practice Provider (APP) service model in fiscal year 2018 to provide consistent standardized clinical care, with surgical trainees rotating monthly, to mitigate the loss of residents over time. We aimed to critically evaluate the impact of an APP run BICU on mortality and quality improvement initiatives. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted to the BICU between July 1, 2016 and June 30, 2020 were eligible for inclusion. All central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), ventilator associated pneumonias (VAP)...

Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone. We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI). A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n 599), hypothermia prevention (n 429), and vascular access (n 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities. In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates. (

Objective. The purpose of this article is to provide a descriptive study of the management of burns in the prehospital setting of a combat zone. Methods. A retrospective chart review was performed of U.S. casualties with >20% total-bodysurface-area thermal burns, transported from the site of injury to Ibn Sina Combat Support Hospital (CSH) between January 1, 2006, and August 30, 2009. Results. Ibn Sina CSH received 225 burn casualties between January 2006 and August 2009. Of these, 48 met the inclusion criteria. The mean Injury Severity Score was 31.7 (range 4 to 75). Prehospital vascular access was obtained in 24 casualties (50%), and 20 of the casualties received fluid resuscitation. Out of the 48 casualties enrolled, 28 (58.3%) did not receive prehospital fluid resuscitation. Of the casualties who received fluid resuscitation, nearly all received volumes in excess of the guidelines established by the American Burn Association and those recommended by the Committee for Tactical Combat Casualty Care. With regard to pain management in the prehospital

Gli autori che pubblicano con RiMe conservano i diritti d'autore e concedono alla rivista il diritto di prima pubblicazione con i lavori contemporaneamente autorizzati ai sensi della Authors who publish with RiMe retain copyright and grant the

During the spring of 2020, the coronavirus disease 2019 (COVID-19) epidemic caused an unprecedented demand for intensive-care resources in the Lombardy region of Italy. Using data on 43,538 hospitalized patients admitted between February 21 and July 12, 2020, we evaluated variations in intensive care unit (ICU) admissions and mortality over the course of 3 periods: the early phase of the pandemic (February 21–March 13), the period of highest pressure on the health-care system (March 14–April 25, when numbers of COVID-19 patients exceeded prepandemic ICU bed capacity), and the declining phase (April 26–July 12). Compared with the early phase, patients aged 70 years or more were less often admitted to an ICU during the period of highest pressure on the health-care system (odds ratio (OR) = 0.47, 95% confidence interval (CI): 0.41, 0.54), with longer ICU delays (incidence rate ratio = 1.82, 95% CI: 1.52, 2.18) and lower chances of dying in the ICU (OR = 0.47, 95% CI: 0.34, 0.64). Patie...

The COVID-19 outbreak affected mental health globally. One of the major concerns following the COVID-19 pandemic was increased incidence of risky behaviors including alcohol consumption. This study evaluates the trend of alcohol poisoning in Loghman-Hakim Hospital (LHH), the main referral center of poisoning in Tehran, during the 2-year period from 1 year prior to 1 year after the onset (February 23rd, 2020) of the COVID-19 epidemic in Iran. All patients admitted with alcohol intoxication from February 23rd, 2019 to February 22nd, 2021 were evaluated and patient data extracted from LHH electronic hospital records. Alcohols were categorized as toxic (methyl alcohol) and non-toxic (ethyl alcohol). Of 2483 patients admitted, 796/14,493 (5.49%) and 1687/13,883 (12.15%) had been hospitalized before and after the onset of the COVID-19 epidemic in Iran, respectively. In total, 140 patients did not survive, of whom 131 (93.6%) were confirmed to have methanol intoxication. Mortality was significantly higher during the outbreak (127 vs 13; P < 0.001; OR: 4.90; CI 95%: 2.75 to 8.73). Among the patients, 503 were younger than age 20. Trend of alcohol intoxication showed increases in children (57 vs 17) and adolescents (246 vs 183) when compared before and after the COVID-19 epidemic outbreak. A total of 955 patients were diagnosed with methanol toxicity which occurred more frequently during the COVID-19 era (877 vs 78; P < 0.001; OR: 10.00; CI 95%: 7.75 to12.82). Interrupted time series analysis (April 2016-February 2021) showed that in the first month of the COVID-19 epidemic (March 2020), there was a significant increase in the alcohol intoxication rate by 13.76% (P < 0.02, CI = [2.42-24.91]). The trend of alcohol intoxication as well as resulting mortality increased in all age groups during the COVID-19 epidemic in Iran, indicating urgent need for the prevention of high-risk alcohol use as well as improved treatment.

This study was conducted to determine the annual number of emergency department (ED) visits and rate of hyperbaric oxygen (HBO 2 ) treatment for carbon monoxide (CO) poisoning in Washington, Idaho, and Montana. All hospital emergency departments and hyperbaric treatment facilities in the region were surveyed by mail and telephone regarding their patient treatment experience for calendar year 1994. Results demonstrated that there were approximately 2.51 million total ED visits in 1994 in the three states studied. Among these, an estimated 1,325 individuals were seen with carbon monoxide poisoning (52.9 CO cases per 100,000 ED visits; 18.1 CO cases per 100,000 population). A total of 91 patients were treated with HBO 2 , yielding an HBO 2 treatment rate of 6.9% of those evaluated in EDs. Extrapolating these figures to the US population suggests that the number of individuals seeking emergency medical care for CO poisoning is much greater than is commonly quoted. Even after correcting for the known increased rate of CO poisoning in the Pacific Northwest, the incidence of nonfatal poisoning appears to be significantly higher than may be appreciated from previous reports.

Most case definitions for carbon monoxide (CO) poisoning include demonstration of an elevated blood carboxyhemoglobin (COHb) concentration. Further, it is generally believed that treatment of CO poisoning is more effective when performed as soon as possible after the exposure. This suggests that a hospital's inability to measure blood COHb could lead to delayed or missed diagnosis or treatment. This study evaluated the ability of hospitals in the Pacific Northwest to measure COHb levels. The clinical laboratory of every acute care hospital in Washington, Idaho, Montana, and Alaska was surveyed regarding the ability to measure COHb levels, the method utilized and the time required. If they could not measure COHb, they were asked whether samples are sent elsewhere, the location of the referral laboratory, and time required. Results were then compared to the list of hospitals referring COpoisoned patients to a regional center for hyperbaric oxygen therapy from 2003-2004. In the four states, only 44% of acute care hospitals have the capability to measure COHb. The remaining 56% send blood samples to other laboratories. The average time to get a result is 10 ؎ 10 min in hospitals with co-oximetry and 904 ؎ 1360 min in those without, a difference of 15 h (p < 0.0001). When samples are sent out, the average distance is 121 miles, often bypassing a hospital with CO-oximetry capability. Over 90% of CO-poisoned patients referred for hyperbaric treatment came from hospitals able to measure COHb. Fewer than one-half of acute care hospitals in a four-state region have the capability to measure COHb levels. This has the potential to significantly impact diagnosis or treatment of patients with acute CO poisoning.

Background: Intentional carbon monoxide (CO) poisoning is responsible for two-thirds of the deaths from CO poisoning in this country and an estimated 15,000 Emergency Department visits annually. Objectives: In an attempt to optimize medical management of such patients, this study was conducted to examine the frequency and types of toxic co-ingestions that may accompany CO inhalation. Methods: Records of all patients treated with hyperbaric oxygen for acute, intentional CO poisoning at a regional referral center for hyperbaric medicine in Seattle from 1980 to 2005 were reviewed. For those where co-ingestions were identified, information about type of poison(s) and results of toxicology screens was recorded and analyzed. Results: Over the 25-year period examined, 433 patients were treated for intentional CO poisoning and records were available for 426. Of those, 188 (42%) had ingested one or more poisons in addition to CO. Ethanol was most common, but a wide variety of other drug classes were also identified. Toxicology screening studies of some type were performed in 49 patients. Conclusions: Toxic coingestions seem to be relatively common in patients treated for intentional CO poisoning. For this reason, providers should be vigilant and open to clinical signs that can't be explained with CO exposure alone, and ready to treat clinical issues that arise from co-ingestions.

Objective: The coronavirus disease (COVID-19) pandemic has disrupted healthcare systems worldwide, resulting in decreased and delayed hospital visits of patients with non-COVID-19-related acute emergencies. We evaluated the impact of the COVID-19 pandemic on the presentation and outcomes of patients with non-COVID-19-related medical and surgical emergencies. Method: All non-COVID-19-related patients hospitalized through emergency departments in three tertiary care hospitals in Saudi Arabia and Bahrain in June and July 2020 were enrolled and categorized into delayed and non-delayed groups (presentation ≥/=24 or &lt;24 h after onset of symptom). Primary outcome was the prevalence and cause of delayed presentation; secondary outcomes included comparative 28-day clinical outcomes (i.e., 28-day mortality, intensive care unit (ICU) admission, invasive mechanical ventilation, and acute surgical interventions). Mean, median, and IQR were used to calculate the primary outcomes and inferentia...

Pandemic Period Covid-19 (p=0,002). Perioada de spitalizare a fost mai mare în pandemie 10±1 zile (p=0,031), fără diferenţe semnificative între grupuri în ceea ce priveşte internarea la Terapie Intensivă (p=0,122). Mortalitatea totală s-a dublat procentual, cu 31 de cazuri (19%) în pandemie şi 28 cazuri (9%) în non-pandemie. (p=0,001). Pandemia COVID-19 a jucat un rol esenţial în tratarea cazurilor de abdomen acut chirurgical. Rata mare de solicitare a serviciilor de urgenţă a întârziat diagnosticul şi tratamentul cazurilor chirurgicale severe. Deoarece amploarea acestei pandemii este fără precedent, protocoalele standard cu modificări minore nu oferă rezultate adecvate. abdomen acut chirurgical, COVID-19, chirurgie de urgenţă, prepandemie, pandemie

Please cite this paper as: Hosseini E, Shojaei L, Karimpour H, Shahbazi F. Potential Drug-Drug Interactions in Critically Ill Medical Patients: A Cross-Sectional Study. J Pharm Care 2018; 6(3-4): 52-57. Introduction prophylactic purposes. This situation may place them at a higher risk for potential drug-drug interactions (pDDIs). Drug interactions may increase hospital stay and total cost (1,2) which include drug-drug interactions, drugfood interactions and drug-disease interactions (3). A wide range of potential drug interactions have been found in previous studies (4-6). Common features among the majority of critically ill patients are their acuity, complex pathophysiologic states and the use of a large number of pharmacologic agents in their management. On average, these patients have six to nine drugs prescribed per day while being cared for in the critical care unit (6). Due to the complexity of the pharmacotherapy involved in the simultaneous use of several drugs and various t...

Background/ Purpose: Surgical exploration has been recommended in all children with acute scrotum. Torsion of the testis (TT) is a surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. However, in many situations, the history, the clinical examination as well as the colour Doppler ultrasonography (DUS) study does not support the diagnosis of TT; and yet many pediatric surgeons still go for surgery in such cases. The aim of this study is to find out if this policy is justified.

To survey US physicians involved in acute stroke care to determine the proportion of hospitals that currently meet the recommended Brain Attack Coalition (BAC) criteria for Primary Stroke Centers (PSC) and obtain opinions regarding the value of stroke centers. Methods: A survey regarding the BAC guidelines for the establishment of stroke centers was mailed to 3,245 US neurologists, neurosurgeons, and emergency physicians. Results: A total of 1,032 responses were received. Seventy-nine percent (range by specialty 58 to 98%) of respondents believed there was a need for stroke centers. If formal stroke center designation were established, 81% (range 72 to 90%) would like their hospital to become a PSC. Although 77% of respondents believed that their hospital currently met recommended criteria for a PSC, only 7% actually meet all recommended elements. However, 44% of hospitals already provide most acute stroke services. The BAC criteria most frequently lacking were continuing medical education for professional stroke center staff, stroke training for emergency department staff, formal establishment of a stroke unit, and designation of a stroke center director. Conclusions: The majority of emergency medicine and neuroscience physician respondents involved in acute stroke care support the designation of primary stroke centers. Although respondents globally overestimated the extent to which their facilities currently meet BAC recommended criteria for PSC, detailed responses suggested that over 40% of hospitals possess substantial existing acute stroke care resources and are poised to function as PSC with modest additional administrative and financial commitment.

Good Samaritan University Hospital (GSUH) has been preliminary approved to become a Level I Trauma Center. The American College of Surgeons (ACS) requires Level I Trauma Centers to have senior surgery residents on the trauma service. To fulfill this requirement, GSUH has established an affiliation with Stony Brook University Hospital, a tertiary care hospital with an Accreditation Council for Graduate Medical Education-approved five-year postgraduate training program in General Surgery, to have senior surgery residents from their training program rotate and provide care to trauma patients beginning in July of 2021. Numerous studies over the past few decades have shown conflicting results on patient outcomes with resident involvement. A majority of the studies published only evaluated residents who were native to the respective hospitals. Our study evaluated the impact of surgery residents visiting from an outside hospital on hospital length of stay (LOS) in admitted trauma patients. As increased hospital LOS is strongly associated with increased hospital-acquired complications, increased healthcare costs, and poor patient experience, we used this to evaluate the efficiency of our trauma team with the addition of visiting surgery residents. A retrospective study was conducted utilizing the hospital's trauma registry. Patients were divided into two groups: the first two years before the addition of surgery residents from July 1st, 2019, to June 30th, 2021, and the second two years after the addition of surgery residents from July 1st, 2021, to June 30th, 2023. The primary outcome measured the hospital LOS between the two groups. Pearson's chi-square test was used to analyze all categorical data, and a t-test was used to compare differences in means. From July 1st, 2019, to June 30th, 2023, a total of 7,081 patients were admitted to the trauma service: 3,411 in the group with no surgery residents, and 3,670 patients in the group with residents (p = 0.052). The primary outcome, hospital LOS, was not significantly affected by the addition of surgery residents to the trauma service. Hospital LOS before surgery residents was 4.40 days compared to with residents at 4.41 days (p = 0.944). Mortality was significantly decreased with resident involvement at 1.9% compared to no residents at 2.7% (p = 0.017). Interestingly, the Emergency Department LOS was significantly longer in the group with residents, 268.82 minutes vs. 232.19 minutes (p = 0.004). The average New Injury Severity Score was 9.02 in the group with no residents and 9.04 in the group with surgery residents (p = 0.927). The majority of traumas in both groups were blunt trauma 96.5% with no residents vs. 97.1% with residents (p = 0.192). The addition of visiting surgery residents to the trauma team did not significantly increase hospital LOS. Ultimately, having visiting residents on the trauma service may enhance resident education without compromising hospital LOS. Training at different hospitals can allow residents to experience different patient populations and different hospital protocols, making them adaptable and more prepared to work in different hospital settings, whether academic or community. Hospitals without their own residency programs could potentially form affiliations with residency programs to meet the ACS requirements, which can bring more patients to their hospitals.

Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

Introduction The concept of “weekend effect”, that is, substandard healthcare during weekends, has never been fully demonstrated, and the different outcomes of emergency surgical patients admitted during weekends may be due to different conditions at admission and/or different therapeutic approaches. Aim of this international audit was to identify any change of pattern of emergency surgical admissions and treatments during weekends. Furthermore, we aimed at investigating the impact of the COVID-19 pandemic on the alleged “weekend effect”. Methods The database of the CovidICE-International Study was interrogated, and 6263 patients were selected for analysis. Non-trauma, 18+ yo patients admitted to 45 emergency surgery units in Europe in the months of March–April 2019 and March–April 2020 were included. Demographic and clinical data were anonymised by the referring centre and centrally collected and analysed with a statistical package. This study was endorsed by the Association of Ita...

Objectives: Trimethoprim/sulfamethoxazole is commonly used to treat melioidosis. Antimicrobial susceptibility testing using the disc diffusion method is commonly used in melioidosis-endemic areas, but may overestimate resistance to trimethoprim/sulfamethoxazole. We performed disc diffusion and Etest on isolates from the first positive culture for all patients presenting to Sappasithiprasong Hospital, Ubon Ratchathani, Thailand, with cultureconfirmed melioidosis between 1992 and 2003. The estimated resistance rate for 1976 clinical Burkholderia pseudomallei isolates was 13% by Etest and 71% by disc diffusion. All isolates classed as either susceptible (n = 358) or as having intermediate resistance (n = 218) on disc diffusion were susceptible by Etest. Only 258 of the 1400 (18%) isolates classed as resistant on disc diffusion were resistant by Etest. Conclusions: Disc diffusion testing of B. pseudomallei may be useful as a limited screening tool in resource poor settings. Isolates assigned as 'susceptible' or 'intermediate' by disc diffusion may be viewed as 'susceptible'; those assigned as 'resistant' require further evaluation by MIC methodology.

Background: Elderly people are at risk for mortality, functional decline, reattendance, and hospitalization after an emergency department visit. Objective: The aim of this study was to evaluate the performance of Identification of Seniors at Risk tool to predict unplanned readmissions after an emergency department visit. Methods: Records of patients aged ⩾65 years, who completed Identification of Seniors at Risk tool as they were being discharged from the emergency department, were analyzed. Patients were called back at 30th, 60th, 90th, 120th, and 180th days after emergency department discharge to assess their readmission to emergency department. Descriptive statistics and receiver operating characteristic curve analysis were performed. Results: This was a single-center study conducted with elderly patients with chronic diseases in a tertiary-level hospital within a period of 10 months with the follow-up calls. During the first month, 1792 patients were admitted to emergency depart...

To recollect the experiences felt by patients during their Intensive Care Unit (ICU) stay and to correlate the memories of those experiences with health-related quality of life (HR-QOL). Methods: The present study is part of a multicenter study meant to evaluate HR-QOL, in adult patients admitted in 10 Portuguese ICUs, between 1 October 2002 and 31 March 2003. At 6 months after ICU discharge, an original questionnaire on experiences felt by patients during their ICU stay was delivered. Simultaneously HR-QOL was evaluated with EQ-5D. There were 1433 admissions. Mortality was 21% in the ICU and 28% in the hospital. At 6 months after ICU discharge, 464 patients completed the recollection questionnaire. Results: 38% of the patients stated not to remember their all ICU stay. From those who remember, ICU environment was described as friendly and calm by 93% of the patients. Sleep was described as being good and enough in 73% of the patients. The experiences reported as being more stressful were tracheal tube aspiration (81%), nose tube (75%), family worries (71%) and pain (64%). 51% of the patients experienced dreams and nightmares during their ICU stay. 14% of these patients stated that those dreams and nightmares disturb their present daily life. 41% of patients reported present sleep disturbances, 38% reported difficulties in concentrating in present daily activities and 36% reported difficulties in remembering recent events. Multiple and linear regression analysis showed that older age, longer ICU stay, higher SAPS II, non-scheduled surgery and multiple trauma, sleep disturbances, daily disturbances by dreams and nightmares, difficulties in concentrating and difficulties in remembering recent events were independent predictors of worst HR-QOL. Conclusions: This study suggests that neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent HR-QOL.

In Australia, extracorporeal membrane oxygenation (ECMO) is one of the most expensive diagnosis-related groups, costing $305 463 per complex admission to the intensive care unit (ICU). [3] Mortality in this group of patients is high, about 43% for respiratory failure and 68% for cardiac failure. 4-5 ECMO is associated with significant risk to the patient and requires specialist training and expertise. [3] Variation in clinical practice for patients supported with ECMO may compromise patient care and outcomes. In order to prepare for the coordination of this complex intervention in Australian ICUs, clinicians need to access accurate data on patients undergoing ECMO. International studies have reviewed resources and management required for ECMO; however, there is an absence of high quality multicentre observational data on the provision of ECMO in Australia. Therefore, the aims of this study were to identify clinical practice guidelines, complication reporting, resource utilisation, and training practices in Australia before the commencement of a national ECMO registry.

Background COVID-19 pandemic, especially during resurgences of cases in hard-hit areas, led to significant shortage of hospital beds. Such shortages may be alleviated through timely and effective forecasting of hospital discharges. The objective of this study is to predict next 7-day discharges of hospitalized COVID-19 patients using daily-based electronic health records (EHR) data. Methods Using EHR data of hospitalized COVID-19 patients from 03/2020-08/2021, we employed ensemble learning to predict next 7-day discharges of individual patients. We used both baseline and daily inpatient features for model training, validation, and test. Baseline features include demographic and clinical characteristics, and comorbidities. The daily inpatient features were vital signs, laboratory tests, medications administered, acute physiological scores, use of ventilator, and use of intensive care unit. 1832 hospitalized patients were identified (12,397 hospital days). Samples were randomly split ...

AimTo describe the characteristics of patients whose end‐of‐life care was initiated in response to a Medical Emergency Team (MET) call and to develop a predictive score to aid prospective identification of these patients.MethodsRetrospective cohort study of all MET calls in a tertiary teaching hospital between April 2010 and March 2011. All inpatients attended by the hospital MET. The main outcome measures were patient demographics, admission features and comorbidities in active and palliative patients, timing, frequency, physiology, and interventions in active and palliative MET calls.ResultsOne thousand, five hundred and sixty‐seven MET calls were called for 1073 patients. Sixty (5.6%) patients had at least one MET call resulting in initiation of end‐of‐life care. Palliative MET call patients compared with active patients were older (76.4 vs 65.9 years; P &lt; 0.0001), had a shorter hospital stay (7.5 vs 12 days; P = 0.0002), had increased in‐hospital mortality (73.3% vs 13.5%; P ...

More than twenty-five years have elapsed since the first Do Not Resuscitate (DNR) policies were proposed. A historical review of the application of DNR policies is provided with its rationale and perceived effects. A viewpoint is presented, that acceptance of implied consent for cardiopulmonary resuscitation (CPR) in hospitalized patients was responsible for drawing up of DNR policies. Unfortunately, the principle of informed consent as related to CPR and DNR policies, has had unintended consequences. Practical results do not indicate that medical practices have become more humane. Abuses of the process go beyond matters of style and experience, in communicating with surrogate decision-makers. Instead of generating compassion and respect for the patient, policies may contribute to cynicism and lack of caring amongst physicians. Overly optimistic dependence on advance directives to reform medical practices, appears unjustified. The concept of futility to limit demands for non-beneficial care is examined. It is unlikely that physicians can routinely invoke futility, as an argument to limit treatments. A re-examination of DNR policies as a defense against technologic imperative is warranted.

Background: Regularly monitoring of educational activities is of undisputed importance in residency training programs. Various educational and training activities can be recorded in a logbook, including giving a lecture, participating in training courses, morning reports, providing particular procedures and skills. Objectives: The current study aimed to compare a newly launched web-based logbook to a paper-based logbook to identify potential strengths and weaknesses. Methods: Emergency medicine residents of postgraduate year 1 (PGY1) and 2 (PGY2) and faculty members participated in the present study. Electronically collected data from February-April 2014 were compared to those of paper logbooks for the same period in the previous year. Furthermore, to evaluate the perspectives of both students and faculty members on the web-based logbook, a survey was implemented. Results: In total 47 residents recorded their activities in the web-based logbook. For the same period in the previous y...

BACKGROUND Some surgeons advocate the usage of tranexamic acid (TXA) in traumatic brain injury (TBI). The aim of this study is to determine the effectiveness and safety of TXA in improving the outcome of TBI patients and in reducing the rate of clot expansion and mortality in TBI as compared to those without TXA. METHODS This is a prospective observational cohort study conducted in Sarawak General Hospital, Malaysia. Patients 12 years of age and older with mild to severe TBI who had a brain computed tomography (CT) done within eight hours of injury were enrolled in the study. A total of 334 patients were recruited from the 5th of August 2016 until the 8th of March 2018 in Sarawak General Hospital. In all 167 of them were administered with TXA and another 167 of the patients were not. The primary outcome expected is the number of good outcomes in isolated TBI patients given TXA. Good outcome is defined by Glasgow Outcome Score-Extended (GOSE) of five and above. Secondary outcome was ...

to the initiating facility was 12 min, 46 s, whereas critical transport was reported to be in excess of 40 min. There was no change in the anticipated number of ALS transports during the study period. Medicare payment for an ALS-RN transport is at least 35% less than the same CCT transport. Savings are similar for third-party insurance and public assistance (Medi-Cal/ Medicaid). Conclusions: ALS-RN transport is a safe, reliable, and cost-effective alternative to critical care transport for STEMI, trauma, and other select patient transports, and should be considered in any venue where there is a significant need for time-sensitive interfacility transports.

Background: We determined the in‐hospital and the long‐term outcomes of primary percutaneous coronary intervention (PCI) for acute left main coronary artery (LMCA) occlusion. Methods: Between 1988 and 2009, 72 patients with acute myocardial infarction (AMI) underwent primary PCI for unprotected LMCA occlusion. The short‐ and the long‐term outcomes of primary PCI in these patients were retrospectively evaluated. Results: Upon arrival, cardiogenic shock was observed in 33 (46%) patients and cardiopulmonary arrest (CPA) in 12 (17%). Twenty‐three (32%) required extracorporeal life support and 64 (89%) intra‐aortic balloon pumping. Although successful reperfusion was achieved in 60 (83%) patients, in‐hospital death was observed in 32 (44%). Multivariate analysis revealed predictors of in‐hospital death to be CPA on arrival (RR, 7.05; 95% CI: 1.28–39.0; P = 0.025). During 1.7 ± 2.9 years of follow‐up, 10 of the 40 hospital survivors died. All presenting CPA on arrival died within 2 years....

Introduction: Multidisciplinary expert team collaboration in the clinical setting, which includes clinical pharmacist involvement can facilitate significant improvements in outcomes and optimize patient management by preventing drug-related problems (DRP). This type of collaboration is particularly valuable in patients with multi-morbidity and polypharmacy such as diabetic foot patients. Evidence regarding the successful integration of a new clinical pharmacist, without previous experience into a unit is still scarce. Therefore, this study aimed to describe and evaluate the actual successful integration process of the clinical pharmacist into a diabetic foot unit by measuring the change in recommendation acceptance rate over time.Methods: A prospective, exploratory treatment effectiveness study based on the recommendation acceptance rate of a new clinical pharmacist introduced into the diabetic foot unit was conducted over a 9- month period. The clinical pharmacist identified medica...

Empirical research on shared mental models (SMM) in virtual environments are almost non-existent. Pre-hospital emergencies presents an opportunity to examine team processes in virtual teams because the dispatcher is geographically separated from the ambulance and at the same time plays a significant role in coordinating, organizing, obtaining, evaluating, and conveying relevant information to the deployed ambulance. The present study aimed at mapping team behavior and cognition in critical real-life emergency medical missions based on the concept of SMM. By investigating the frequencies of coordinating mechanisms and team competencies based on voice recordings from real-life missions, differences in team behavior between low and high-complexity missions were investigated. Lower frequencies of team competencies and coordinating mechanisms were found in high compared to low-complexity missions. The results showed a different profile in communication between high and low-complexity missions with more frequent use of both coordinating mechanisms and team competencies in low-complexity missions. Furthermore, the profiles revealed that SMM and closed loop communication were the only coordinating mechanism used, and leadership and team orientation were the only competencies exercised. It was concluded that the lack of visual input of a team member during team interaction could lead to team process loss due to a breakdown of the team into sub-units. Potential improvement of team behavior is discussed within the SMM framework.

Background: Appropriate dispatch criteria and helicopter emergency medical service (HEMS) crew decisions are crucial for avoiding over-triage and reducing the number of concurrencies. The aim of the present study was to compare patient outcomes after completed HEMS missions and missions cancelled by the HEMS due to concurrencies. Methods: Missions cancelled due to concurrencies (AMB group) and completed HEMS missions (HEMS group) in Western Norway from 2004 to 2013 were assessed. Outcomes were survival to hospital discharge, physiology score in the emergency department, emergency interventions in the hospital, type of department for patient admittance, and length of hospital stay. Results: Survival to discharge was similar in the two groups. Onethird of the primary missions in the HEMS group and 13% in the AMB group were patients with pre-hospital conditions posing an acute threat to life. In a sub group analysis of these patients, HEMS patients were younger, more often admitted to an intensive care unit, and had an increased survival to discharge. In addition, the HEMS group had a greater proportion of patients with deranged physiology in the emergency department according to an early warning score. Conclusion: Patients in the HEMS group seemed to be critically ill more often and received more emergency interventions, but the two groups had similar in-hospital mortality. Patients with prehospital signs of acute threat to life were younger and presented increased survival in the HEMS group. For emergency calls and dispatch of ambulance helicopter emergency services (HEMS), there is a challenge in activating a mission when appropriate, and in not activating a mission when it appears to be not appropriate based on the information in the call. This study assessed outcomes when emergency calls in one system which were triaged to HEMS or to no HEMS. For almost 40 years, the physician-staffed helicopter emergency medical service (HEMS) in Norway has supplemented the ground ambulance service and on-call general practitioners (GPs) in the municipalities. The HEMS covers most of the populated mainland within a 30-min flight time.

Background: Critically ill patients need to be immediately identified, properly managed, and rapidly transported to definitive care. Extensive prehospital times may increase mortality in selected patient groups. The on-scene time is a part of the prehospital interval that can be decreased, as transport times are determined mostly by the distance to the hospital. Identifying factors that affect on-scene time can improve training, protocols, and decision making. Our objectives were to assess on-scene time in the Helicopter Emergency Medical Service (HEMS) in our region and selected factors that may affect it in specific and severe conditions. Methods: This retrospective cohort study evaluated on-scene time and factors that may affect it for 9757 emergency primary missions by the three HEMSs in western Norway between 2009 and 2013, using graphics and descriptive statistics. Results: The overall median on-scene time was 10 minutes (IQR 5-16). The median on-scene time in patients with penetrating torso injuries was 5 minutes (IQR 3-10), whereas in cardiac arrest patients it was 20 minutes (IQR 13-28). Based on multivariate linear regression analysis, the severity of the patient's condition, advanced interventions performed, mode of transport, and trauma missions increased the on-scene time. Endotracheal intubation increased the OST by almost 10 minutes. Treatment prior to HEMS arrival reduced the on-scene time in patients suffering from acute myocardial infarction. Discussion: We found a short OST in preselected conditions compared to other studies. For the various patient subgroups, the strength of association between factors and OST varied. The time spent on-scene and its influencing factors were dependent on the patient's condition. Our results provide a basis for efforts to improve decision making and reduce OST for selected patient groups. Conclusions: The most important factors associated with increased on-scene time were the severity of the patient's condition, the need for intubation or intravenous analgesic, helicopter transport, and trauma missions.