The latest medical research on Emergency Medicine

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Managing and Measuring Emergency Department Care: Results of the Fourth Emergency Department Benchmarking Definitions Summit.

Academic Emergency Medicine

A shared language and vocabulary are essential for managing emergency department (ED) operations. This 4th ED Benchmarking Alliance (EDBA) Summit brought together experts in the field to review, update, and add to key definitions and metrics of ED operations.

Summit objectives were to review and revise existing definitions, define and characterize new practices related to ED operations, and introduce financial and regulatory definitions affecting ED reimbursement.

Forty-six ED operations, data management, and benchmarking experts were invited to participate in the EDBA summit. Before arrival, experts were provided with documents from the three prior summits and assigned to update the terminology. Materials and publications related to standards of ED operations were considered and discussed. Each group submitted a revised set of definitions prior to the summit. Significantly revised, topical, or controversial recommendations were discussed amongst all summit participants. The goal of the in-person discussion was to reach consensus on definitions. Workgroup leaders made changes to reflect the discussion, which was revised with public and stakeholder feedback.

The entire EDBA dictionary was updated and expanded. This manuscript focuses on an update and discussion of definitions related to specific topics that changed since the last summit, specifically ED intake, boarding, diversion, and observation care. In addition, an extensive new glossary of financial and regulatory terminology germane to the practice of emergency medicine is included.

A complete and precise set of operational definitions, time intervals, and utilization measures is necessary for timely and effective ED care. A common language of financial and regulatory definitions that affect ED operations is included for the first time. This manuscript and its companion dictionary should serve as a resource to ED leadership, researchers, informatics and health policy leaders, and regulatory bodies.

Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update.

Scandinavian Journal of

Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS.

A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts.

Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template.

Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study.

Scandinavian Journal of

Acute dyspnoea is common among ambulance patients, but little is known of the patients' experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.

We performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.

We included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6-10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6-9) to 4 (2-5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.

We found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients' experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Hot off the Press: SGEM #285 - Adult Coloring for Anxiety in the Emergency Department.

Academic Emergency Medicine

Adult coloring books have been shown to reduce anxiety in healthy students as well as oncology patients in hospital settings. Anxiety and stress ca...

Feasibility Study of a Quasi-Experimental Regional Opioid Safety Prescribing Program in Veterans Health Administration Emergency Departments.

Academic Emergency Medicine

The Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) was implemented in 2013 and was associated with a 25% relative decrease in the dispensing of opioids. Although Emergency Department (ED) providers play a role in the initiation and continuation of opioids, the incumbent OSI did not target EDs.

The goal of this feasibility study was to leverage the existing VHA OSI and test a novel ED-based quality improvement (QI) program to decrease opioid prescribing in multiple ED settings.

This was a quasi-experimental study of phased-in implementation of a quality improvement ED-based OSI. The general setting for this pilot were four VHA EDs across the Veterans Integrated Services Network (VISN) region 19: Denver, Oklahoma City, Muskogee, and Salt Lake City. We developed and disseminated a dashboard to assess ED-specific prescribing rates and an ED-tailored toolkit to implement the program. Academic Detailing pharmacists provided focused audits-and-feedback with the highest prescribing providers. We measured change in ED-provider prescribing rate of opioids for patients discharged from the ED, by provider and aggregated up to facility-level, pre- and post-implementation.

Interrupted time series analysis of provider-level data from the program implementation sites indicated a significant decrease in the trend for proportion of opioid prescriptions relative to the pre-intervention trend. The results of the analysis suggest that the intervention was associated with accelerating the rate at which ED provider prescribing rates decreased.

Due to the high volume of patients and the vital role the ED plays in patient treatment and hospital admissions, it is evident that the ED is an important site for QI programs as well as the implementation of opioid safety measures. Given the findings of this pilot, we believe implementation of a national Veterans Affairs (VA) ED OSI implementation is feasible practice.

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years.

Academic Emergency Medicine

Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions.

This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates.

Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05).

Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.

Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance.

EMA - Emergency Medicine Australasia

Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance.

This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation.

There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses.

Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.

Insights into the epidemiology of cardiopulmonary resuscitation-induced consciousness in out-of-hospital cardiac arrest.

EMA - Emergency Medicine Australasia

To describe the characteristics and outcomes of cardiopulmonary resuscitation (CPR)-induced consciousness patients from a large database of out-of-hospital cardiac arrest (OHCA).

Included were adult patients, attended between January 2007 and December 2018 by the Queensland Ambulance Service, where resuscitation was attempted by paramedics. Manual review of records was undertaken to identify CPR-induced consciousness cases. Patients exhibiting purposeful limb/body movement during CPR, with or without displaying other signs, were considered to be CPR-induced consciousness. Characteristics and outcomes of CPR-induced consciousness patients were compared to those without CPR-induced consciousness.

A total of 23 011 OHCA patients were included; of these, 52 (0.23%) were CPR-induced consciousness. This translates into an incidence rate of 2.3 cases per 1000 adult resuscitation attempts over 12 years. Combativeness/agitation was the most common sign of CPR-induced consciousness, described in 34.6% (18/52) of patients. CPR-induced consciousness patients had numerically higher rates of return of spontaneous circulation on hospital arrival (51.9% vs 28.6%), discharge survival (46.2% vs 15.1%) and 30-day survival (46.2% vs 14.7%), than those without CPR-induced consciousness; however, CPR-induced consciousness was not found to be an independent predictor of survival. Higher proportions of CPR-induced consciousness patients had arrest witnessed by paramedics, occurring in public places, of cardiac aetiology and initial shockable rhythm, than patients without CPR-induced consciousness.

CPR-induced consciousness in OHCA appears to be associated with higher survival rates. Standardised guidelines on recognition and management of CPR-induced consciousness remain to be established.

Lactobacillus reuteri for treatment of infant colic.

Academic Emergency Medicine

Infant colic affects approximately 1 in 5 infants under 3 months of age and is defined by crying and/or fussing > 3 hours per day for ≥ 3 days per ...

A critical COVID metric: your ED staff infection rate.

Academic Emergency Medicine

If you're like me, in recent days you've experienced moments of fear. Feelings like when you woke up in bed at night as a kid, and saw a dark shado...

Application of Different Commercial Tourniquets by Laypersons: Would Public-access Tourniquets Work Without Training?

Academic Emergency Medicine

The White House "Stop the Bleed" campaign has renewed interest in public-access bleeding kits and the use of tourniquets by the lay public. The objective of this study was to determine which type of tourniquet could be applied most effectively by the lay public using only manufacturer instructions included with each tourniquet.

This prospective study randomized participants to one of four different tourniquets (SOFTT-W, CAT, RMT, SWAT-T). Participants were all over 18 years of age. Individuals with prior military, EMS, or patient-care medical experience were excluded. Using only the manufacturer's packaging instructions, participants were asked to apply a tourniquet on a simulated bleeding arm. A trained observer noted if tourniquet application by the participant was effective, partially effective, or ineffective based on reduction or cessation of simulated blood flow. Participant's application of the tourniquet was also timed (in seconds) by the observer. The primary outcome of our study was the effectiveness of application for each of the four tourniquets. Secondary outcome was time to effective application.

A total of 176 participants were enrolled. For untrained laypersons the RMT had the highest effective application rate of 64.4% and was also the most rapidly applied at 100.9 ± 8.8 seconds (95% confidence interval [CI] = 83.1 to 118.6). The SWAT-T had the highest ineffective application rate (55.5%) than any other tourniquet type (p = 0.002). There was no effect of age or education on time to application for any tourniquet type. Effective applications were performed significantly faster than partially effective or ineffective applications (93.4 ± 5.8 [95% CI = 81.7 to 104.9] vs. 136.7 ± 8.7 [95% CI = 118.8 to 154.7] vs. 151.9 ± 8.3 [95% CI = 135.2 to 168.6]; p ≤ 0.001). There was no difference in time between partial and ineffective applications (p = 0.261).

Our study suggests that laypersons could benefit from prior training to effectively apply tourniquets in emergency situations. Of the tourniquets studied, the RMT was the most effectively and most rapidly applied.

Opioid-induced Euphoria Among Emergency Department Patients With Acute Severe Pain: An Analysis of Data From a Randomized Trial.

Academic Emergency Medicine

Parenteral opioids are commonly used to treat acute severe pain. We measured pleasurable sensations in patients administered intravenous analgesics to determine if these sensations were associated with receipt of an opioid, after controlling for relief of pain. Pleasurable sensations not accounted for by relief of pain were considered opioid-induced euphoria.

These data were from a randomized study of 1 mg of hydromorphone versus 120 mg of lidocaine for abdominal pain. To assess euphoria, participants were asked to provide a 0 to 10 response to each of these questions: 1) How good did the medication make you feel? 2) How high did the medication make you feel? and 3) How happy did the medication make you feel? Pain at baseline and 30 minutes was also measured on a 0 to 10 scale. To determine the relative importance of pain relief versus medication type, we built three linear regression models in which each euphoria question was the dependent variable and pain relief, medication type, and medication-induced side effects were the independent variables.

Seventy-seven patients received lidocaine and 77 hydromorphone. Hydromorphone patients reported greater pain improvement than lidocaine patients (mean difference = 1.5, 95% confidence interval [CI] = 0.6 to 2.3) and higher scores on all three euphoria questions ("feeling good" difference = 1.9, 95% CI = 0.8 to 3.0; "feeling high" difference = 1.5, 95% CI = 0.4 to 2.7; "feeling happy" difference = 1.7, 95% CI = 0.6 to 2.8). In the regression models, hydromorphone administration (β-coefficient = 0.16, p = 0.03) and pain relief (β-coefficient = 0.45, p < 0.01) were both associated with "feeling good." "Feeling high" and "feeling happy" were associated with pain improvement (p < 0.01) but not with hydromorphone administration (p = 0.07 for "high" and p = 0.06 for "happy"). Medication-induced side effects were not associated with these measures of euphoria.

Among emergency department patients with acute pain, hydromorphone-induced euphoria, though measurable, was generally less important for patients than relief of pain.