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Background: Early detection and management of hypothermia are determinants in the consequences of the injury. Various factors are involved in the progress of accidental hypothermia in these patients. Objectives: This study was done to determine the prevalence of accidental hypothermia and its related factors in trauma patients admitted to the emergency department (ED). Methods: In this prospective observational study, 123 trauma patients, who were transferred to the ED of Ayatollah Mosavi hospital, Zanjan, Iran by emergency medical technicians during November 2018, were selected. The patientschr('39') core body temperature (CBT) was measured through a calibrated tympanic thermometer on admission, 30 minutes after admission, and at the time of leaving the ED. Personal, clinical, environmental, and caring variables were evaluated as factors associated with hypothermia. Data were analyzed using descriptive statistics and multiple linear regression by SPSS16. The significance level was considered to be 5%. Results: The prevalence of accidental hypothermia in the ED was 43.1%. The patientchr('39')s arrival CBT (β: 0.333, P-value

Objective: To evaluate the utilization of the parenteral morphine in Emergency Department (ED) using the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) system. Methods: In this retrospective cross-sectional study, morphine administration was recorded in 4-year time period from January 2013 to December 2016 in the ED of a referral center. The dose of the administered morphine was evaluated using the ATC/DDD system. The ATC/DDD of the parenteral morphine was calculated based on the world health organization (WHO). The data was evaluated based on the different diagnosis and conditions using the ATC/DDD protocol. Results: In this study, 500 patients referred to ED with mean age of 48.29 ± 10.10 years were included. There were 306 (61.2%) men and 194 (38.8%) women among the patients. The lowest and highest DDD of parenteral morphine were 0.1 and 0.43, respectively. The utilization of parenteral morphine was significantly higher in men when compared to women (pppp Conclusion: The utilization of parenteral morphine in the ED of our center was higher than the WHO standard dosage. The morphine utilization was associated with male gender, opium addiction and TCA consumption.

Introduction: The number of mortality due to traffic accidents is still becoming a global burden. In addition SDGs 2030 has set a target to decrease the number of mortality and global injuries due to traffic accidents. The purpose of this study was to analysis the risk of mortality due to traffic accidents in the Eemergency Department (ED) of dr.Soebandi Hospital Regional, Jember Regency. Method: A retrospective observational study was carried out in the ED by studying medical records of the traffic accident patients aged ≥16 years. The sampling technique was used simple random sampling with the sample size 250. The study was collected data with Modified Rapid Emergency Medicine Score. This study result was analyzed with frequency distribution and Chi-Square test. Results: The result showed respondents who experienced traffic accidents mostly was 20-29 years old (19.6%). The majority of the patient was men (68,4%). The riders of two/three-wheeled vehicles who suffered traffic accidents reached 73.2%. Most of the accidents that occurred at 06.00-11.59 AM were around 37.6%. Generally, traffic accidents occur to drivers as much as 68.4%. The number of types of head trauma as much as 57,2%. This study showed that 94,8% patients were at low risk of mortality. There were significant relationship between risk of mortality and the role in vehicle use (p-value = 0,043). Conclusions: Almost all patients have a low risk of mortality in the ED of dr. Soebandi Hospital Jember Regency.

Aim: The aim of the study was to analyze whether a patient’s opinion is related to the effect of analgesic treatment. Methods: The study was conducted using a survey questionnaire among adult patients admitted to the hospital emergency department in March 2021. The Numerical Rating Scale (NRS) was used to assess pain. Patients were asked to rate the intensity of pain during their stay in the emergency department in three situations: (1) at admission; (2) during the stay; and (3) upon discharge. The relationships between qualitative variables were assessed by the chi-squared test. Significance was set at p < 0.05. Results: There was no statistical dependence between the patient’s opinion about the medical institution and results of the effectiveness of analgesic treatments (p = 0.056). The highest percentage of patients satisfied with the received treatment were those who did not feel pain during ED discharge (94.12%), and the lowest were those who complained of severe pain during ED discharge (63.91%). The average mark for the functioning and organization of the emergency department was 7.44 (±2.04). Only 54 patients (29.83%) had taken pain medication before deciding to visit ED. Conclusions: No statistical dependency between the effect of the analgesic treatment and the patient’s opinion has been observed. The majority of patients with pain discomfort visit emergency departments without looking for consultation in other locations or without taking analgesics. In the considered institution, patients were satisfied with the analgesic treatment, staff performance, and with the organization of the department.

Background: Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event. We aimed to identify clinically relevant subphenotypes at high risk of IHCA in the emergency department (ED).Methods: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory markers, and IHCA status. Group-based trajectory modeling was performed.Results: There were 37,697 adult ED patients with a total of 1,507,121 data points across all vital-sign categories. Three to four trajectory groups per vital-sign category were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, recurring tachypnea, and low and fluctuating oxygen saturation. The IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have higher levels of C-reactive protein, lactic acid, cardiac troponin I, and D-dimer. Multivariable analysis revealed that hypothermia (adjusted odds ratio [aOR], 2.20; 95% confidence interval [95%CI], 1.35–3.57) and recurring tachypnea (aOR 2.44; 95%CI, 1.24–4.79) were independently associated with IHCA.Conclusions: We identified five novel vital-sign sub-phenotypes associated with a higher likelihood of IHCA, with distinct patterns in clinical course and laboratory markers. A better understanding of the pre-IHCA vital-sign trajectories may help with the early identification of deteriorating patients.

Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis.Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7).Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were “uninterpretable” according to experts' consensus, 80 (46.8 %) were rated “normal” and 86 (50.3 %) “abnormal”. The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs.Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting.

Objectives: Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED). Methods: This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained. Results: Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006]. Conclusion: Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level.

Background: Length of stay (LOS) in emergency department (ED) defined as "the time from patient's registration in ED to discharge" is a key healthcare quality measure in ED. Prolonged LOS has been linked with adverse health outcomes and patient's dissatisfaction. Several countries have implemented a maximum LOS targets ranging from four to six hours. However, several reports from different countries show that significant proportions of ED patients breach the LOS targets. Currently, the healthcare system in Qatar has a four-hour waiting time target in ED. The main aim of this thesis was to estimate the proportion of patients exceeding the four-hour LOS target in adult ED in AWH and identify associated factors. The objectives of the thesis were: (a) to identify the overall proportion of ED visits that breach the 4-hour LOS target between January and April 2019, inclusive; (b) to identify any variations in monthly proportions of ED visits breaching the four-hour LOS target between January and April 2019, inclusive; (c) to identify any differences in LOS time in main processes within patient flow in ED by breaching the LOS target status among discharged and admitted patients; (d) To identify the main factors (patient- level factors and throughput process factors in ED and the hospital) associated with breaching the 4-hour LOS target. Method: A retrospective cohort study design was used to review all adult ED visits for patients aged 14 years or older in AWH from January 1st, 2019 to April 30th, 2019, inclusive. The computerized health information system (CERNER) was used to extract study data. The main outcome variables were LOS in ED and the breaching status of the 4- hour LOS target on daily basis as a binary variable (not-breached=? 4 hours, breached =>4 hours), where the data were collected on daily basis. Process template and logistic regression were used to analyze the data. Results: The proportion of patients exceeded the LOS was 37% with a median LOS of 423 minutes. Among longer stay patients (>4 hours), as compared to short stay patients (

Background: Given the scarcity of resources, the increasing use of emergency departments (ED) represents a major challenge for the care of emergency patients. Current health policy interventions focus on restructuring emergency care with the help of patient re-direction into outpatient treatment structures. A precise analysis of ED utilization, taking into account treatment urgency, is essential for demand-oriented adjustments of emergency care structures. Methods: Temporal and seasonal trends in the use of EDs were investigated, considering treatment urgency and hospital mortality. Secondary data of 287,119 ED visits between 2015 and 2017 of the two EDs of Charité Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum were analyzed. Result: EDs were used significantly more frequently on weekends than on weekdays (Mdn = 290 vs. 245 visits/day; p < 0.001). The proportion of less urgent, outpatient emergency visits on weekends was above average. Holiday periods were characterized by at least 6, and at most 176 additional ED visits. In a comparison of different holidays, most ED visits were observed at New Year (+68% above average). In addition, a significant increase in in-hospital mortality on holidays was evident among inpatients admitted to hospital via the ED (3.0 vs. 3.2%; p < 0.001), with New Year's Day being particularly striking (5.4%). Conclusion: These results suggest that, in particular, the resource planning of outpatient emergency treatment capacities on weekends and holidays should be adapted to the increased volume of non-urgent visits in EDs. Nevertheless, treatment capacities for the care of urgent, inpatient emergencies should not be disregarded and further research projects are necessary to investigate the causes of increased mortality during holiday periods.

In contrast to patients with an apparent life-threatening event (ALTE), the American Academy of Pediatrics recommends very limited evaluation for patients categorized as lower-risk brief resolved unexplained event (BRUE). This retrospective review aims to explore potential missed diagnostic opportunities for patients with a lower-risk BRUE (n = 10) through comparison with a subset of patients with ALTE (n = 72). None of the patients with a lower-risk BRUE had laboratory, imaging or ancillary studies that were diagnostic. Among patients with ALTE, 5 had laboratory and 3 had imaging studies that were diagnostic. None of the patients with a lower-risk BRUE had recurrent events during hospitalization or a serious underlying diagnosis identified within the 90 day follow-up period. As recommended by the AAP, patients with a lower-risk BRUE do not need diagnostic evaluation and can be discharged home with outpatient follow-up.

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED.Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre–post intervention changes in fear and state anxiety.Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's dz = 0.22–0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content “a lot” as well as enjoyed listening to the audiobook “a lot.” Without prompting, 15% of participants requested to listen to an additional audiobook.Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

A core performance target for the English National Health Service (NHS) concerns waiting times at Emergency Departments (EDs), with the aim of minimising long waits. We investigate the drivers of long waits. We analyse weekly data for all major EDs in England from April 2011 to March 2016. A Poisson model with ED fixed effects is used to explore the impact on long (> 4 h) waits of variations in demand (population need and patient case-mix) and supply (emergency physicians, introduction of a Minor Injury Unit (MIU), inpatient bed occupancy, delayed discharges and long-term care). We assess overall ED waits and waits on a trolley (gurney) before admission. We also investigate variation in performance among EDs. The rate of long overall waits is higher in EDs serving older patients (4.2%), where a higher proportion of attendees leave without being treated (15.1%), in EDs with a higher death rate (3.3%) and in those located in hospitals with greater bed occupancy (1.5%). These factors are also significantly associated with higher rates of long trolley waits. The introduction of a co-located MIU is significantly and positively associated with long overall waits, but not with trolley waits. There is substantial variation in waits among EDs that cannot be explained by observed demand and supply characteristics. The drivers of long waits are only partially understood but addressing them is likely to require a multi-faceted approach. EDs with high rates of unexplained long waits would repay further investigation to ascertain how they might improve.

peer-reviewed Background: Admission to the Emergency Department (ED) can be stressful for older people with advanced dementia and their family members. Previous research has tended to emphasise the negatives and deficits in care. Little research seeks out what works well or what matters in dementia care experiences in this context. Knowledge embedded in the experiences of family members accompanying an older person with dementia in ED and the experiences of emergency nurses caring for them may be part of the solution in developing strategies for improvement. Aim: This study was conducted in a large ED in the southwest of Ireland. It sought to explore the experiences of family members accompanying an older person with dementia in ED and the experiences of ED nurses caring for the older person with dementia and their family member in an episode of care. The intention was to generate new knowledge to co-create future possibilities for development. Four academic papers are weaved into the thesis. Methodology: Appreciative Inquiry (AI) was the participatory methodology used in this study. AI is an approach which focuses on generating new insights to open the gateway for possibilities and alternative ways of doing. This study pertains to the Discovery and Dream Phases of AI. Methods: In the Discovery Phase, data generation methods were participant observation with ED nurses (n=12) caring for older people with dementia in ED and interviews with family members (n=15) who accompanied an older person with dementia in ED. Interviews were framed through a storytelling approach. In the Dream Phase, ED nurses (n=10) participated in a Learning Conversations Session for further data generation and to co-analyse findings from the Discovery Phase. Data generation methods in the Dream Phase were appreciative framing and dialogue, storytelling and collective sensemaking. These methods were creatively used to maximise the potential for generating new knowledge about worked well in enhancing the experiences of dementia care in ED. The six step approach developed by Braun and Clarke (2006) provided a structure to guide thematic analysis. Findings: This resulted in a number of fresh insights; seeing things from a different perspective, balancing relationship centred and technical care, working in the moment as a sympathetic presence and collaborating in caring for an older person with dementia in ED. The common thread was that the quality of relationships shape the quality of care experiences for family members and ED nurses. In a technical and task orientated environment such as ED, the value of relationship centred care is sometimes underestimated. Despite contextual challenges, it was possible for ED nurses in this study to blend relationship centred and technical approaches to care. Alliances between ED nurses and family members may be pivotal in enhancing experiences of dementia care in ED. This study showed that informal collaborations between ED nurses and family members were happening every day. These collaborations could be strengthened if ED nurses had the courage to ask family members how they would like things to be. To do this, ED nurses would need to overcome their fear of not being able to meet family member wishes or expectations. AI methodology encouraged a deliberate stance away from deficits and negatives which enabled ED nurses to explore situational complexity, vulnerability and fears as well as moments of excellence. Unearthing moments of excellence which sometimes go unnoticed or unrecognised was an important step in stimulating new thinking around what works well and how this could happen more of the time. Conclusion: The outcomes of this research have the potential to contribute to the existing knowledge base in that they provide new insights into what matters and is valued in experiences of dementia care in ED and also generate knowledge about how to operationalise relationship centred care as a pivotal part of emergency nursing practice

Syncope is a common presentation to Emergency Departments (EDs). Estimates on the frequency of visits (0.6-1.7%) and subsequent rates of hospitalizations (12-85%) vary according to country. The initial ED evaluation for syncope consists of a detailed history, physical examination and 12-lead electrocardiogram (ECG). The use of additional diagnostic testing and specialist evaluation should be based on this initial evaluation rather than an unstructured approach of broad-based testing. Risk stratification performed in the ED is important for estimating prognosis, triage decisions and to establish urgency of any further work-up. The primary approach to risk stratification focuses on identifying high- and low-risk predictors. The use of prediction tools may be used to aid in physician decision-making; however, they have not performed better than the clinical judgment of emergency room physicians. Following risk stratification, decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities. For those deemed intermediate risk, access to specialist assessment and related testing may occur in a syncope unit in the emergency department, as an outpatient, or in a less formal care pathway and is highly dependent on the local healthcare system. For syncope patients presenting to the ED, ~0.8% die and 10.3% suffer a non-fatal severe outcome within 30 days.

Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs. Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos. Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia. Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care.

The combination of the progressive growth of an aging population, increased life expectancy and a greater number of chronic diseases all contribute significantly to the growing demand for emergency medical care, and thus, causing saturation in Emergency Departments (EDs). This saturation is usually due to the admission of non-urgent patients, who constitute a high percentage of patients in an ED. The Agent-based Model (ABM) is one of the most important tools that helps to study complex systems and explores the emergent behavior of this type of department. Its simulation more accurately reflects the complexity of the operation of real systems. Our proposal is the design of an ABM to schedule the access of these non-critical patients into an ED, which can be useful for the service management dealing with the actual growing demand for emergency care. We suppose that a relocation of these non-critical patients within the expected input pattern, provided initially by historical records, enables a reduction in waiting time for all patients, and therefore, it will lead to an improvement in the quality of service. It would also allow us to avoid long waiting times. This research offers the availability of relevant knowledge for Emergency Department managers in order to help them make decisions to improve the quality of the service, in anticipation of the expected growing demand of the service in the very near future.

Objectives: To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany. Design: Prospective cohort study. Setting: Single centre University Hospital Emergency Department. Participants: Adult, non-surgical ED patients. Exposure: A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS. Primary and secondary outcome measures: Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality). Results: A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95%CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95%CI 0.77 to 1.89; p=0.420). Conclusions: The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care. Trial registration number: U1111-1119-7564; Post-results

Head injury is the most common cause of neurologic disability and mortality in children. We had hypothesized that in children with isolated skull fractures (SFs) and a normal neurological examination on presentation, the risk of neurosurgical intervention is very low. We retrospectively reviewed the medical records of all children aged six to sixteen years presenting to our Level 1 trauma center with traumatic brain injuries between January 1, 2006 and December 31, 2014. We also analyzed the National Trauma Data Bank (NTDB) research data set for the years 2012-2014 using the same metrics. During this study period, our center admitted 575 children with skull fractures, 197 of which were isolated (no associated intracranial lesions (ICLs)). Of the 197 patients with isolated SFs, 155 had a normal neurological examination at presentation. In these patients, there were no fatalities and only three (1.9%) required surgery, all for the elevation of the depressed skull fracture. Analyzing the NTDB yielded similar results. In 5,194 children with isolated SFs and a normal neurological examination on presentation, there were no fatalities and 249 (4.8%) required neurosurgical intervention, almost all involving craniotomy/craniectomy and/or elevation of the SF segments. In conclusion, children with non-depressed isolated skull fractures and a normal Glasgow coma scale (GCS) at the time of initial presentation are at extremely low risk of death or needing neurosurgical intervention.

This study aimed to assess whether hypothermia is an independent predictor of mortality in trauma patients in the condition of defining hypothermia as body temperatures of &lt, 36 &deg, C. Data of all hospitalized adult trauma patients recorded in the Trauma Registry System at a level I trauma center between 1 January 2009 and 12 December 2015 were retrospectively reviewed. A multivariate logistic regression analysis was performed in order to identify factors related to mortality. In addition, hypothermia and normothermia were defined as temperatures &lt, C and from 36 &deg, C to 38 &deg, C, respectively. Propensity score-matched study groups of hypothermia and normothermia patients in a 1:1 ratio were grouped for mortality assessment after adjusting for potential confounders such as age, sex, preexisting comorbidities, and injury severity score (ISS). Of 23,705 enrolled patients, a total of 401 hypothermic patients and 13,368 normothermic patients were included in this study. Only 3.0% of patients had hypothermia upon arrival at the emergency department (ED). Compared to normothermic patients, hypothermic patients had a significantly higher rate of abbreviated injury scale (AIS) scores of &ge, 3 in the head/neck, thorax, and abdomen and higher ISS. The mortality rate in hypothermic patients was significantly higher than that in normothermic patients (13.5% vs. 2.3%, odds ratio (OR): 6.6, 95% confidence interval (CI): 4.86&ndash, 9.01, p &lt, 0.001). Of the 399 well-balanced propensity score-matched pairs, there was no significant difference in mortality (13.0% vs. 9.3%, OR: 1.5, 95% CI: 0.94&ndash, 2.29, p = 0.115). However, multivariate logistic regression analysis revealed that patients with low body temperature were significantly associated with the mortality outcome. This study revealed that low body temperature is associated with the mortality outcome in the multivariate logistic regression analysis but not in the propensity score matching (PSM) model that compared patients with hypothermia defined as body temperatures of &lt, C to those who had normothermia. These contradicting observations indicated the limitation of the traditional definition of body temperature for the diagnosis of hypothermia. Prospective randomized control trials are needed to determine the relationship between hypothermia following trauma and the clinical outcome.

Rationale: Diabetic ketoacidosis is a serious and potentially life-threatening acute complication of diabetes mellitus (DM). Euglycemic diabetic ketoacidosis (eDKA) is however challenging to identify in the emergency department (ED) due to absence of marked hyperglycemia, often leading to delayed diagnosis and treatment. eDKA has been recently found to be associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors, one of the newest classes of antidiabetics, though there are very limited reports implicating dapagliflozin as the offending agent in ED patients. Here we report a type 2 diabetic patient who presented to the ED with eDKA secondary to dapagliflozin administration. Patient concerns: A 61-year-old Asian female with underlying type 2 DM presented to our ED with body weakness, dyspnea, nausea, vomiting, and mild abdominal pain for the past 2 days. These symptoms were preceded by poor oral intake for 1 week due to severe toothache. Dapagliflozin was recently added to her antidiabetic drug regimen of metformin and glibenclamide 2 weeks ago. Diagnoses: Arterial blood gases showed a picture of severe metabolic acidosis with an elevated anion gap, while ketones were elevated in blood and positive in urine. Blood glucose was mildly elevated at 180 mg/dL. Serum lactate levels were normal. Our patient was thus diagnosed with eDKA. Intervention: Our patient was promptly admitted to the intensive care unit and treated for eDKA through intravenous rehydration therapy with insulin infusion. Outcomes: Serial blood gas analyses showed gradual resolution of the patient's ketoacidosis with normalized anion gap and clearance of serum ketones. She was discharged uneventfully on day 4, with permanent cessation of dapagliflozin administration. Lessons: Life-threatening eDKA as a complication of dapagliflozin is a challenging and easilymissed diagnosis in the ED. Such an ED presentation is very rare, nevertheless emergency physicians are reminded to consider the diagnosis of eDKA in a patient whose drug regimen includes any SGLT2 inhibitor, especially if the patient presents with nausea, vomiting, abdominal pain, dyspnea, lethargy, and is clinically dehydrated. These patients should then be investigated with ketone studies and blood gas analyses regardless of blood glucose levels for prompt diagnosis and treatment.

Background This study aimed to describe the pathological findings and to analyze clinical predictors of abnormal imaging findings in patients presenting to the emergency department (ED) with syncope. Methods The database was retrospectively reviewed for all patients who underwent cranial computed tomography (CT) or magnetic resonance imaging (MRI), having the symptom of syncope. Patients were included only if they were from the emergency department and excluded if were under 18 years of age, had known recent intracranial pathology, known brain tumor, or having a history of trauma. The primary outcome was assumed as abnormal head CT or MRI including intracranial hemorrhage, acute or subacute stroke, and newly diagnosed brain mass. Univariate and multivariate logistic regression analysis was utilized to determine the association between clinical variables and any significant pathology in either CT or MR scan. Results Total of 1230 syncope (717 men and 513 women; range, 18–92 years; mean, 54.5 years) as presenting symptoms were identified in patients receiving either cranial CT or MR scan in the ED. Abnormal findings related to the syncope were observed in 47 (3.8%) patients. The following predictor variables were found to be significantly correlated with acutely abnormal head CT and MRI: a focal neurologic deficit, history of malignancy, hypertension, and age greater than 60 years. Conclusions Our data offer that the identification of predictor variables has a potential to decrease the routine use of head CT and MRI in patients admitting to the ED with syncope.

The primary goal of Emergency Department (ED) physicians is to discriminate between individuals at low risk, who can be safely discharged, and patients at high risk, who require prompt hospitalization. The problem of correctly classifying patients is an issue involving not only clinical but also managerial aspects, since reducing the rate of admission of patients to EDs could dramatically cut costs. Nevertheless, a trade-off might arise due to the need to find a balance between economic interests and the health conditions of patients. This work considers patients in EDs after a syncope event and presents a comparative analysis between two models: a multivariate logistic regression model, as proposed by the scientific community to stratify the expected risk of severe outcomes in the short and long run, and Artificial Neural Networks (ANNs), an innovative model. The analysis highlights differences in correct classification of severe outcomes at 10 days (98.30% vs. 94.07%) and 1 year (97.67% vs. 96.40%), pointing to the superiority of Neural Networks. According to the results, there is also a significant superiority of ANNs in terms of false negatives both at 10 days (3.70% vs. 5.93%) and at 1 year (2.33% vs. 10.07%). However, considering the false positives, the adoption of ANNs would cause an increase in hospital costs, highlighting the potential trade-off which policy makers might face.

Background Triple-rule-out (TRO) computed tomographic (CT) angiography is a recent technique for evaluation of the coronary arteries, aorta, pulmonary arteries, and adjacent intrathoracic structures simultaneously for patients with acute chest pain. Objectives To assess the validity and efficacy of Triple-rule-out (TRO) computed tomographic (CT) angiography in diagnosis of different vascular causes of chest pain in the emergency department. Methods Between April 2013 and December 2014, 40 patients presenting with non-specific acute chest pain to the emergency department performed Triple-rule-out (TRO) computed tomographic (CT) angiography utilizing a biphasic contrast injection technique. The CT angiographic images were interpreted prospectively for detection of any pulmonary, coronary or aortic vascular abnormalities. Results The study revealed 20 cases (50%) with only coronary lesions, 5 cases (12.5%) with only pulmonary lesions, 10 cases (25%) with only aortic lesions and 3 cases (7.5%) with combined coronary/aortic lesions. 2 cases (5%) showed no significant vascular abnormality. Conclusion An optimized TRO protocol with concomitant reduced radiation exposure and efficient contrast agent administration provides a reliable tool for evaluation of coronary, aortic and pulmonary arteries in the emergency department.

Introduction Social Work (SW) referrals made in the emergency department (ED) highlight the weaknesses in the existing support system for vulnerable and disadvantaged patients. SW personnel play a pivotal role in some EDs but are not integrated into the team in several jurisdictions. Our objective was to provide a detailed description of the need for SW support in the ED setting by describing SW consultation patterns in an urban ED location. Methods A three-year analysis of ED SW referrals made through a network of four acute care hospitals serving a city population of 1.2 million inhabitants where social workers operate from 8 a.m. to 10 p.m. The study design was descriptive reporting proportions. The descriptors of interest were the types of ED patients receiving SW consultations and the reasons for patient referral to the SW Department. Results During the study period, there were 46,970 SW consultations, representing 8.02% of the 572,804 patients who visited the ED across Calgary, yielding 42.9 referrals per day to social workers through the ED. Consultations for domestic violence were three times more prevalent for women (6% of referrals). However, domestic violence consultations were still an active issue for men (1.9%). Comparisons by age group yielded illness adjustments (15.3%), discharge planning (31.2%), and legal decision making (23.9%) as the most common reasons for referral of patients over 75 years old; 92.8% of patients over 75 years were admitted following the SW consultation. Reasons for deferral of patients under 30 years of age were illness adjustments (12.2%), discharge planning (16.4 %), and legal decision making (1.4%); 57.3% of patients under 30 years were admitted following the consultation. Addiction/drug use and homelessness were more common in those under the age of 30, comprising 24.1% and 15.4% of the SW referrals, respectively, compared to 1.6% and 0.4% of referrals for those over age 75, respectively. Conclusions The demand for SW support is significant and complex in these large urban EDs. However, the impact on patient care and resource use is substantial, and the data indicates that SW integration may be of universal benefit to EDs. Further studies are warranted to accurately characterize the amount and type of SW necessary for optimal patient outcomes and hospital resource use.

Background Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences. Methods A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies. Results Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29–62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05–1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex. Conclusion Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation. Trial registration PROSPERO CRD42017074845. Electronic supplementary material The online version of this article (10.1186/s12877-018-0848-6) contains supplementary material, which is available to authorized users.

Introduction: In the modern healthcare systems of the developed countries, patients’ need for more quality health services is strong. Patient satisfaction is an important indicator of the quality of services provided by the Emergency Departments. Aim: The measurement of satisfaction of the patients’ needs by the health services provided at the Emergency Department. Material and Methods: The studied sample consisted of 128 patients who arrived at the Emergency Department of a private clinic. For data collection a special designed questrionnaire was used. Results: The quality of the provided health services is determined by objective criteria related to the consistency and the duration of the services, and the personnel’s capacity to respond to the patient’s needs, part of which are the co-ordination, the politeness and the good communication. 46,1% were men and 53.9% were women. 50 % were married and 56.3% mentioned that they were in good shape.72.7% had not been hospitalized for the past 12 months. The correlation between age and the first 23 questions showed (p Conclusions: The most determined factors for the patients’ satisfaction were proven the easy access to the Emergency Department, in connection with little waiting and a nice environment, and the immediate response of the medical-nursing personnel, which is reflected, apart from its scientific grounding, in its politeness, calmness, discretion and securing of privacy.

IntroductionWe previously reported that benzodiazepine detoxification for alcohol withdrawal using symptom-triggered therapy (STT) with oral diazepam reduced length of stay (LOS) and cumulative benzodiazepine dose by comparison with standard fixed-dose regimen. In this study, we aim to describe the feasibility of STT in an emergency department (ED) short-stay clinical decision unit (CDU) setting.MethodsIn this retrospective cohort study, we describe our experience with STT over a full calendar year (2014) in the CDU. A retrospective chart review was conducted and data collection included demographics, clinical details, total cumulative dose of diazepam, receipt of parenteral thiamine, LOS and disposition.Results5% (n=174) of 3222 admissions to CDU required STT. Collapse or seizure (41%, n=71) and alcohol withdrawal (21%, n=37) were the most common reasons recorded for admission to CDU in those who required STT. Median Alcohol Use Disorders Identification Test score was 25 and 112 patients (64%) had at least one Clinical Institute Withdrawal Assessment for Alcohol revised measurement ≥10, triggering a dose of diazepam (20 mg). The median cumulative oral diazepam dose was 20 mg while 24 (15%) patients received a cumulative dose of 100 mg or more. Median time for STT was 12 hours (IQR=12, R=1–48). 3% (n=5) of patients required further general hospital admission and median LOS in CDU, was 22 hours (IQR=20, R=1–168).ConclusionSTT is potentially feasible as a rapid and effective approach to managing alcohol withdrawal syndrome in the ED/CDU short-stay inpatient setting where patient LOS is generally less than 24 hours.

Background We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS). Methods The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry. Results Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert. Discussion In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival. Conclusion In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0399-4) contains supplementary material, which is available to authorized users.

Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients.Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD.A qualitative interpretive descriptive approach was used.Rural emergency departments across northern Alberta.Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position.Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive.Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis:The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses.The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care.Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.La dialyze à domicile présente plusieurs avantages pour les patients, mais ces derniers ont besoin de soutien pour gérer une modalité de dialyze à domicile comme la dialyze péritonéale (DP). Les urgences des milieux ruraux constituent un important filet de sécurité pour les patients requérant des soins médicaux, notamment pour des complications de la DP telles que la péritonite. Les patients du nord de l’Alberta sont répartis sur un vaste territoire et résident parfois à bonne distance d’un center où recevoir une formation sur la DP. Pourtant, plusieurs centers ruraux n’offrent pas de soins pour ces patients.Notre objectif était de recenser les facteurs facilitant ou entravant la prestation de soins infirmiers dans les urgences rurales du nord de l’Alberta pour les patients traités par DP.Une approche qualitative, interprétative et descriptive a été utilisée.Les urgences situées en milieu rural dans tout le nord de l’Alberta.Un échantillonnage ciblé a été utilisé pour rechercher des participants dans l’une des quatre urgences d’hôpitaux de soins aigus ruraux du nord de l’Alberta. Six infirmières autorisées et une infirmière auxiliaire autorisée, dont l’expérience professionnelle variait de 2 à 18 ans, ont accepté de participer à l’étude. Deux participantes étaient gestionnaires d’unité, deux étaient infirmières cliniciennes enseignantes, les trois autres faisaient partie du personnel infirmier, l’une d’elles occupant un poste de direction.Des interviews individuelles semi-structurées, dont le guide était basé sur une revue de la littérature, ont été menées par téléphone. Les entretiens se sont poursuivis jusqu’à saturation des données, c’est-à-dire jusqu’à ce qu’aucune nouvelle information ne soit obtenue. Les interviews ont été enregistrées et transcrites verbatim; les notes d’observation ont été consignées. Une approche comparative constante a été employée pour procéder à l’analyze des données. Le processus de codage était à la fois déductif (tiré de la documentation) et inductif.Sept participantes ont été questionnées et l’analyze des données a permis de dégager quatre thèmes principaux et un sous-thème:Ces résultats reflètent les perceptions des participantes; un point de vue qui pourrait différer de celui d’infirmières œuvrant dans d’autres régions du pays. Aussi, plusieurs participantes occupaient des postes de direction; leur perspective pourrait diverger de celle des infirmières et infirmiers de première ligne.Nos résultats soulignent la nécessité de disposer de documentation sur la DP et de ressources à la fois matérielles et humaines pour s’occuper de ces patients. Il importe aussi de renforcer le soutien des médecins locaux et des néphrologues afin d’offrir des soins de grande qualité aux patients suivant des traitements de dialyze péritonéale.Sans objet. Il ne s’agit pas d’un essai clinique; l’étude n’a pas impliqué une éventuelle affectation des participants à un groupe de traitement.

ObjectivesTo identify risk factors for inpatient mortality after patients’ emergency admission and to create a novel model predicting inpatient mortality risk.DesignThis was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score.SettingA single tertiary hospital in Singapore.ParticipantsAll adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes).Main outcome measureThe primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs.Results15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively.ConclusionWe developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.

Background: Few data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome. Methods: A single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units. Results: Seventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%. Conclusion: Refusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted. doi: http://dx.doi.org/10.4021/jocmr1501w

There is increasing recognition of the deleterious effects of poor nutrition on health care outcomes. Older patients appear particularly vulnerable to the effects of undernutrition. This includes both low intake as patients and chronic preadmission undernutrition. This study investigates nutrition during a critical intervening period when patients present to a hospital emergency department (ED) in the first half of the day. One third of observed patients sustained periadmission fasts in excess of 18 hours. This fasting period showed significant positive correlation to age (correlation coefficient = 0.34, P < 0.05). Analysis of the results by gender showed that men who were older than the average cohort age of 53.6 years fasted for a significantly longer period in the hospital than their younger counterparts (P < 0.02). This comparison did not reach significant levels for female patients (P > 0.05). This study raises the question as to whether food should be routinely provided in the ED unless there is reason to withhold it. Particular care should be taken to avoid unnecessary delays in offering food to older patients. There may also be a need to ensure that geriatric care indicators are considered individually for each gender.

The progressive growth of aging, increased life expectancy and a greater number of chronic diseases contribute significantly to the growing demand of emergency medical care, and thus, on saturation of Emergency Departments. This is one of the most important current problems in healthcare systems worldwide. This work proposes an analytical model to calculate the theoretical throughput of a particular sanitary staff configuration in a Hospital Emergency Department, which is, the number of patients it can attend per unit time given its composition. The analytical model validation is based on data generated by simulation of the real system, based on an agent based model of the system, which makes it possible to take into account different valid sanitary staff configurations and different number of patients entering the emergency service. In fact, we aim to evaluate the response capacity of an ED, specifically of doctors, nurses, admission and triage personnel, who make up a specific sanitary staff configuration, for any possible configuration, according to the patient flow throughout the service. It would not be possible to test the different possible situations in the real system and this is the main reason why we obtain the necessary information about the system performance for the validation of the model using a simulator as a sensor of the real system. The theoretical throughput is a measure of the response capacity to patient's attention in the system and, moreover, it will be a reference in order to make possible a model for planning the entry of non-critical patients into the service by its relocation in the current input pattern, which is an immediate future goal in our current research. This research offers the availability of relevant knowledge to the managers of the Emergency Departments to make decisions to improve the quality of the service in anticipation of the expected growing demand of the service in the very near future.

Higher stage, reduced access to surgical resection and radiotherapy, and significantly lower overall survival regardless of histology subtypes among lung cancer patients who presents through emergency department, stress out the importance of earlier diagnosis of lung cancer patients so that initial presentation through emergency department can be reduced

Background: Acute abdominal pain (AAP) accounts for 7–10% of all Emergency Department (ED) visits. Nevertheless, the epidemiology of AAP in the ED is scarcely known. The aim of this study was to investigate the epidemiology and the outcomes of AAP in an adult population admitted to an urban ED. Methods: We made a retrospective analysis of all records of ED visits for AAP during the year 2014. All the patients with repeated ED admissions for AAP within 5 and 30 days were scrutinized. Five thousand three hundred and forty cases of AAP were analyzed. Results: The mean age was 49 years. The most frequent causes were nonspecific abdominal pain (NSAP) (31.46%), and renal colic (31.18%). Biliary colic/cholecystitis, and diverticulitis were more prevalent in patients aged >65 years (13.17% vs . 5.95%, and 7.28% vs . 2.47%, respectively). Appendicitis (i.e., 4.54% vs . 1.47%) and renal colic (34.48% vs . 20.84%) were more frequent in patients aged Conclusions: Our study showed that AAP represented 5.76% of total ED visits. Two conditions (i.e., NSAP and renal colic) represented >60% of all causes. A large use of active clinical observations during ED stay (52% of our patients) lead to a negligible percentage of changing diagnosis at the second visit.

Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency department (ED). Pharmacological therapy is often applied for these symptoms, such as vestibular suppressants, anti-emetics and benzodiazepines. However, every medication is accompanied with unavoidable side-effects. There are several research articles providing evidence of acupuncture treating dizziness and vertigo but few studies of acupuncture as an emergent intervention in ED. We performed a pilot cohort study to evaluate the efficacy and safety of acupuncture in treating patients with dizziness and vertigo in ED. A total of 60 participants, recruited in ED, were divided into acupuncture and control group. Life-threatening conditions or central nervous system disorders were excluded to ensure participants’ safety. The clinical effect of treating dizziness and vertigo was evaluated by performing statistical analyses on data collected from questionnaires of Dizziness Handicap Inventory (DHI), Visual Analog Scale (VAS) of dizziness and vertigo, and heart rate variability (HRV). The variation of VAS demonstrated a significant decrease (p-value: 0.001 and p-value: 0.037) between two groups after two different durations: 30 mins and 7 days. The variation of DHI showed no significant difference after 7 days. HRV revealed a significant increase in high frequency (HF) in the acupuncture group. No adverse event was reported in this study. Acupuncture demonstrates a significant immediate effect in reducing discomforts and VAS of both dizziness and vertigo. This study provides clinical evidence on the efficacy and safety of acupuncture to treat dizziness and vertigo in the emergency department. ClinicalTrials.gov ID: NCT02358239 . Registered 5 February 2015

Background The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center. Methods Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared. Results At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%). Conclusion The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.

Tyrimo tikslas – Ištirti skubios pagalbos skyriaus slaugytojų patiriamo smurto paplitimą ir valdymą. Tyrimo uždaviniai: 1) nustatyti skubios pagalbos skyriaus slaugytojų darbe patiriamo smurto rūšis ir dažnį, jo pasiskirstymą pagal darbą pamainomis; 2) ištirti, pagrindinius smurto šaltinius su kuriais susiduria slaugytojai dirbantys skubios pagalbos skyriuose; 3) įvertinti smurto poveikį skubios pagalbos skyrių slaugytojų emocinei sveikatai; 4) nustatyti smurto valdymo būdus skubios pagalbos skyriuose slaugytojų požiūriu. Tyrimo metodas – 2013 metų sausio 14 – vasario 28 dienomis buvo vykdoma anoniminė anketinė apklausa. Apklausoje dalyvavo Vilniaus, Kauno, Panevėžio bei Šiaulių miestų didžiūjų ligoninių, skubios pagalbos skyriuose dirbantys slaugytojai ( n=213, atsako dažnis – 88 proc.). Respondentų tarpe buvo trys vyrai, likusios moterys. Tyrimui buvo naudojamas klausimynas smurto darbo vietoje tyrimams, įvairių šalių sveikatos priežiūros sektoriuje, atlikti. Gautas sutikimas atlikti tyrimą iš Bioetikos komiteto ( 2013-01-09 Nr. BEC-KS(M)-181 ). Tyrimo rezultatai. Tyrimo rezultatai parodė, jog 20,2 proc. visų apklaustų respondentų, teigė patyrę fizinį smurtą. Apklaustieji slaugytojai (46,5 proc.) teigė, buvę fizinio smurto SPS liudininkais. Respondentai patyrė ir psichologinio smurto apraiškas, tokias kaip užgauliojimus (81,2 proc.), grasinimus (67,1 proc.), patyčias (45,1 proc.), seksualinį priekabiavimą (6,6 proc.), rasinį priekabiavimą (1,4 proc.). Tyrimo išvados... [toliau žr. visą tekstą] Aim: to investigate prevalence and management of violence experienced by nurses in emergency department. Tasks: 1) to identify types and frequency of violence experienced by nurses in emergency department, and categorize it according to work shifts; 2) to define main sources of violence experienced by nurses in emergency department; 3) to evaluate impact of violence to emotional health emergency department nurses; 4) to identify methods management of violence according to emergency department nurses. Methods. Anonymous questionnairing was performed during Jan 14 – Feb 28, 2013. Nurses of emergency department from eight biggest hospitals of Vilnius, Kaunas, Panevėžys and Šiauliai, participated the survey (n=213, response rate was 88 %). Answers of three male and rest female respondents were included into study. The questionnaire “Workplace violence in the health sector. Country case studies research instruments” was used. The Committee on Bioethics at Lithuanian University of Health Sciences approved the study. Results: Results of the study indicate that 20.2 percent of respondents affirmed their experience of physical violence. 46.5 percent of nurses questioned witnessed physical violence in ED. Respondents experienced appearances of psychological violence like abuse (81.2 percent), threats (67.1 percent), bullying (45.1 percent), sexual harassment (6.6 percent) and racial harassment (1.4 percent). Conclusions: Nurses of ED do experience physical and psychological... [to full text]

Aim: to investigate prevalence and management of violence experienced by nurses in emergency department. Tasks: 1) to identify types and frequency of violence experienced by nurses in emergency department, and categorize it according to work shifts; 2) to define main sources of violence experienced by nurses in emergency department; 3) to evaluate impact of violence to emotional health emergency department nurses; 4) to identify methods management of violence according to emergency department nurses. Methods. Anonymous questionnairing was performed during Jan 14 – Feb 28, 2013. Nurses of emergency department from eight biggest hospitals of Vilnius, Kaunas, Panevėžys and Šiauliai, participated the survey (n=213, response rate was 88 %). Answers of three male and rest female respondents were included into study. The questionnaire “Workplace violence in the health sector. Country case studies research instruments” was used. The Committee on Bioethics at Lithuanian University of Health Sciences approved the study. Results: Results of the study indicate that 20.2 percent of respondents affirmed their experience of physical violence. 46.5 percent of nurses questioned witnessed physical violence in ED. Respondents experienced appearances of psychological violence like abuse (81.2 percent), threats (67.1 percent), bullying (45.1 percent), sexual harassment (6.6 percent) and racial harassment (1.4 percent). Conclusions: Nurses of ED do experience physical and psychological violence. Main indications of violence arise from mail subjects. Nurses experience violence most frequently from insober or emotionally unstable patients. Violence experienced by nurses impacts their emotional health. The majority of nurses are not satisfied with methods of resolving violent incidents in ED as far as usually no efforts are applied to investigate these episodes. Development and establishing of security methods along with improving the working environment is most common approach when struggling to prevalence of violence in ED. Majority of nurses foresee great benefits to manage violence in their workplace in such factors as improved security measures, improved workplace surroundings, restricted public access, patient screening, restricted exchange of money at the workplace, increased staff numbers, special equipment or clothing, training, investment in human resource development.

Background Algal blooms of Karenia brevis, a harmful marine algae, occur almost annually off the west coast of Florida. At high concentrations, K. brevis blooms can cause harm through the release of potent toxins, known as brevetoxins, to the atmosphere. Epidemiologic studies suggest that aerosolized brevetoxins are linked to respiratory illnesses in humans. Objectives We hypothesized a relationship between K. brevis blooms and respiratory illness visits to hospital emergency departments (EDs) while controlling for environmental factors, disease, and tourism. We sought to use this relationship to estimate the costs of illness associated with aerosolized brevetoxins. Methods We developed a statistical exposure–response model to express hypotheses about the relationship between respiratory illnesses and bloom events. We estimated the model with data on ED visits, K. brevis cell densities, and measures of pollen, pollutants, respiratory disease, and intra-annual population changes. Results We found that lagged K. brevis cell counts, low air temperatures, influenza outbreaks, high pollen counts, and tourist visits helped explain the number of respiratory-specific ED diagnoses. The capitalized estimated marginal costs of illness for ED respiratory illnesses associated with K. brevis blooms in Sarasota County, Florida, alone ranged from $0.5 to $4 million, depending on bloom severity. Conclusions Blooms of K. brevis lead to significant economic impacts. The costs of illness of ED visits are a conservative estimate of the total economic impacts. It will become increasingly necessary to understand the scale of the economic losses associated with K. brevis blooms to make rational choices about appropriate mitigation.

Introduction Asthma is a continuous significant health problem. Strategies for treating exacerbations are best adapted and implemented at a local level. Severe exacerbations are potentially life threatening, and their treatment requires close supervision. The severity of the exacerbation determines the treatment administered. Indices of severity, particularly peak expiratory flow (PEF), pulse rate, respiratory rate, and pulse oximetry should be monitored during treatment. Aim of the work The aim of this work was to assess the effect of the implementation of the Global Initiative for Asthma (GINA) guidelines in the prognosis and the outcome of asthma exacerbation in the emergency department. Subjects and methods The study was conducted on one hundred asthmatic patients. All patients were informed about the study and gave their consents. Patients were subjected to full history taking and clinical evaluation. Investigations were done in the form of peak flow rate (PFR) measurement, pulse oximetry assessment, ABG analysis (for only 17 patients), chest X-ray (it is not routinely recommended) and complete blood count (if needed). Then patients were classified according to their attacks. All patients were managed according to GINA guidelines. Results Older patients were significantly suffering from severe to life threatening attacks than younger patients. We found that 12% of patients had occupational related asthma in relation to 88% of patients had non-occupational related asthma. There were no statistical significant differences between classification of severity of current attack and previous emergency department (ED) visits/year. There were no statistical significant differences between the studied groups regarding temperature. Systolic and diastolic blood pressure had statistically significant lower values in patients with severe to life threatening attacks than those with mild to moderate attacks. Severe to life threatening group had respiratory rate higher than mild to moderate group. Mild to moderate group had PEF and SaO 2 % higher than severe to life threatening group. PEF was statistically higher post treatment than pre treatment. Three patients of 17 had PaCo 2 >45 mmHg with hypoxemia and respiratory acidosis and they admitted to the intensive care unit (ICU). All patients in ED were assisted to determine the severity of asthma concomitant with administration of initial treatment (plan A), which is oxygen to achieve O 2 saturation ⩾92%, inhaled B2 adrenergic bronchodilator and an oral or intravenous dose of corticosteroids. Five patients met a good response so they enter in (plan C1). Seventy-five patients met with the criteria of moderate episode they go to plan B1, 68 patients of them (about 90%) had a good response within 2 h so go to plan C1 and the rest 7 patients (10%) had an incomplete response go to plan C2. Twenty patients met with criteria of severe episode, 17 of them (85%) with incomplete response move to plan C2, and the rest 3 patients (15%) had a poor response and moved to plan C3, no improvement noticed so they were admitted to the ICU. Hospitalization was done to 11 patients who met a poor response (plan C2), 86 patients were discharged from the ED (73 patients from plan C1 and 13 patients from plan C2). Severe to life threatening group stayed in ED longer than mild to moderate group. Conclusions and recommendations All patients presenting in the emergency department with asthma exacerbations should be evaluated and triaged immediately and must be treated according to their severity of classification using GINA guidelines. Measurements of airflow obstruction, using peak expiratory flow, can help to guide therapy for acute asthma. Continuous monitoring of oxyhaemoglobin saturation by pulse oximetry should be undertaken for all patients with acute exacerbation of asthma. We must; educate patients in ED about the nature of asthma and its therapy, educate patients how to use inhalers, encourage patients to use spirometer at home and discharge each patient with ED-asthma discharge plan.

Purpose To determine the rate of cerebrospinal fluid (CSF) pleocytosis among children presenting with status epilepticus (SE) without proven central nervous system infection. Method We performed a retrospective cross-sectional study of all patients aged one month to 21 years of age who were evaluated in a single pediatric emergency department (ED) for SE between 1995 and 2012. We limited our study to those children who had a CSF culture obtained and excluded those children with proven viral or bacterial infection. We defined SE in a patient who had a single seizure or a cluster of seizures without regaining consciousness which lasted 30min or longer. We defined CSF pleocytosis as a CSF white blood cells (WBC)>10cells/mm 3 and a peripheral leukocytosis as WBC≥15,000cells/mm 3 . We compared the rate of CSF pleocytosis between children with and without peripheral leukocytosis using the Fisher's exact test. Results We identified 289 ED visits for SE, of which 178 (62%) met study inclusion criteria. Seven children (4%, 95% confidence interval 1.7–8.2%) had CSF pleocytosis. More children with peripheral leukocytosis had CSF pleocytosis: (8.6% with peripheral leukocytosis vs. 0.9% without leukocytosis, p =0.01). Conclusion CSF pleocytosis is relatively uncommon among children with prolonged seizures, even in the presence of peripheral leukocytosis. Therefore, all children with CSF pleocytosis after status epilepticus need comprehensive evaluation for central nervous system infection.