The authors undertook a systematic search using electronic databases, citation lists and expert contacts to identify all diagnostic cohort studies of patients presenting with suspected acute coronary syndrome that compared H-FABP at presentation to a reference standard based on the Universal definition of MI. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Meta-analysis was conducted using Bayesian Markov chain Monte Carlo simulation.

The authors included eight studies of quantitative H-FABP and nine studies of qualitative H-FABP. The summary estimates of sensitivity and specificity were 81% (95% prediction interval 50% to 95%) and 80% (26% to 98%) respectively for the quantitative assays and 68% (11% to 97%) and 92% (20% to 100%) respectively for the qualitative assays. Four studies reported the sensitivity of troponin and H-FABP at presentation in which the combination was considered positive if either test was positive. The addition of H-FABP to troponin increased sensitivity from 42–75% to 76–97% but decreased specificity from 94–100% to 65–93%.

H-FABP has modest sensitivity and specificity for MI at presentation but estimates are subject to substantial uncertainty and primary data are subject to substantial heterogeneity. H-FABP may have a role alongside troponin in improving early sensitivity but comparison with high sensitivity troponin assays is required.

Patients presenting to five Emergency Centres during July 2011 were eligible for inclusion. Patients under the age of 12, after-hour presentations, missing folders and folders with incomplete notes were excluded. Emergency physicians with EPCUS exposure were responsible for data collection. They were all blinded to the study's aim. Summary statistics describe the proportion of clinical cases and procedures for which EPCUS was used. One investigator assessed the adequacy of the curriculum by matching the clinical indications of each module with the presenting complaint and final diagnosis of each patient. The ultrasound modules were ranked according to the frequency of their clinical indications. -Statistics are reported on 10% randomly selected cases to quantify interobserver agreement.

The study included 2971 patients. Ultrasound assisted with diagnosis in 384 (12.92%) patients and in 34 (1.14%) procedures. A total of 1933 EPCUS procedures were indicated in 1844 (66.07%) patients. The five most frequently indicated modules were pulmonary, musculoskeletal, cardiac, focused assessment with sonography of HIV/tuberculosis co-infection and renal. The interobserver agreement () was 0.602 (95% CI 0.559 to 0.645).

This study was an attempt to ensure an evidence-based approach to assess the adequacy of the EPCUS core curriculum in South Africa. The results illustrate that our local burden of disease may require a change of the current core curriculum.

An evidence-based flow chart was created with criteria based on trauma mechanism, physical examination and laboratory analyses to indicate appropriateness of conventional radiography (CR), sonography and CT of head, cervical spine and trunk. To evaluate this protocol, the authors prospectively included 81 consecutive patients. Collected data included protocol adherence and number and type of performed CR and CT scans. The authors also determined the time needed to perform radiological investigations, adverse events in the CT room and clinically relevant missed injuries after 1-month clinical follow-up.

There was 99% adherence to the protocol concerning CT. Seventy-nine patients (98%) received one or more CT scans: 72 (89%) had thoracoabdominal, 78 (96%) cervical spine and 54 (67%) had cranial CT. In 30 patients, one or more CT scans of body regions could be omitted. In 38%, CR was wrongly omitted or performed incorrectly at a variance with the protocol. No major adverse events occurred in the CT room and no clinically relevant injuries were missed.

The authors introduced a diagnostic protocol that seems feasible and safe for the evaluation of adult blunt high-energy trauma patients. Implementation of this protocol has the potential to reduce unnecessary radiological investigations, especially CT scans.

To clarify what factors led to precautions among general workers who displayed preventive behaviours against radiation following the nuclear disasters in Fukushima.

Descriptive study of preventive behaviours among general workers 3–5 months following the nuclear disasters. The subjects were 1394 regular workers who took part in radiation seminars conducted by the Fukushima Occupational Health Promotion Center between July and August 2011. Of 1217 responses, 1110 eligible responses were included in this study. This anonymous questionnaire survey was asking for characteristics and questions on preventive behaviours following the nuclear disasters. The authors assessed the contribution of each variable by a logistic regression analysis.

Keeping track of environmental radiation levels and washing hands and gargling were significantly more frequent among female subjects, older age and workers residing up to approximately 80 km away from the power plants. Washing hands and gargling were also related with living with children. Wearing a mask when leaving home and buying bottled water were significantly more often observed with female subjects and workers residing up to 80 km. Refraining from going outdoors was positively associated with workers residing up to 80 km and workers living with children.

These results provide information that may help with the targeting of health information after a nuclear disaster. This may contribute to determining an order of priority when distributing information after a nuclear disaster.

To identify possible predictors of low work ability, including occupational stress and quality of life, among emergency medicine employees.

A cross-sectional study was conducted from May 2010 till July 2010 in the Institute of Emergency Medicine in the City of Zagreb. Questionnaires were distributed to all employees with gathered total sample of 125 subjects (39 physicians, 38 medical nurses /technicians and 48 drivers). Data were collected using the socio-demographic questions, occupational stress assessment, work ability index (WAI) and WHO quality of life (WHOQOL-BREF) questionnaires.

Emergency physicians were significantly more exposed to public criticism (p=0.008) but drivers had more exposure to hazards at workplace (p=0.001) regarding other employee groups. Binary logistic regression model showed two significant predictors of lower work ability (WAI score <37): lower physical WHO-BREF domain (OR=0.78; 95% CI 0.68 to 0.89; p<0.001) and the professional and intellectual demands (OR=1.09; 95% CI 1.01 to 1.19; p=0.043).

Strenuous physical activity should be reduced in order to increase the overall work ability of the emergency medicine employees and better structural organisation and introduction of a residency in emergency medicine should significantly improve total work ability among emergency physicians.

Participants were junior doctors with no prior experience of surgical airways and second year medical students at the end of their head and neck anatomy course. Nine participants were asked to place an emergency cricothyroidotomy in an undissected embalmed cadaver using only a No 26 scalpel and a dismantled ballpoint pen (Papermate Flexigrip Ultra, external diameter 8.9 mm; internal diameter 7.0 mm). Times were recorded and direct visualisation by dissection was used to assess placement and complications.

Nine participants performed a total of 14 separate cricothyroidtomies on separate cadavers. Landmarks were palpable by researchers in 10 of the 14 cadavers. Eight of 14 (57%) procedures were deemed successful. No major vascular injury occurred. Injuries to the thyroid and cricoid cartilages were common; four of 14 (29%) of these injuries were fractures.

In embalmed cadavers, inexperienced junior doctors and medical students with no prior training were able to place a successful cricothyroidotomy slightly more than half the time. It suggests that surgical cricothyroidotomy with a ballpoint pen and blade is a feasible option in extremis. It is unknown whether junior doctors from other specialties, such as emergency medicine, would perform better.

The authors conducted a randomised controlled trial. After 24 h of conventional first aid training, the participants either attended an experimental lesson to reduce barriers to helping or followed a control lesson. The authors used a deception test to measure the time between the start of the unannounced simulated emergency and seeking help behaviour and the number of particular helping actions.

The authors randomised 72 participants to both groups. 22 participants were included in the analysis for the experimental group and 36 in the control group. The authors found no statistically or clinically significant differences for any of the outcome measures. The time until seeking help (geometrical mean and 95% CI) was 55.5 s (42.9 to 72.0) in the experimental group and 56.5 s (43.0 to 74.3) in the control group. 57% of the participants asked a bystander to seek help, 40% left the victim to seek help themselves and 3% did not seek any help.

Supplementary training on dealing with barriers to helping did not alter the helping behaviour. The timing and appropriateness of the aid provided can be improved.

The authors registered this trial at ClinicalTrials.gov as NCT00954161.

To assess the on-site provision required to support a large multisport event for people with learning disabilities and to ascertain the impact on the local hospital services.

On-site consultations were documented on SOLGB medical record forms. Referrals to the local ED and UCC were identified from the SOLGB medical notes or from the ED/UCC attendance codes, as a specific code was applied to all patients related to the games.

581 on-site consultations were documented at SOLGB 2009, of which 95% of these were for athletes. 477 treatments were completed in total, of which 444 were undertaken on-site (93%). 20 people attended the ED; there were no documented attendances at the UCC. 17 of the 20 attendances at the ED were athletes competing.

Allocation of the healthcare team was appropriate, with the exception of one sport, where a doctor was moved from a nearby event to consult on 13 occasions. Attendances to the local ED and UCC were minimal. Therefore, the model of on-site medical care that was used, which led to minimal impact on NHS resources, will support the arrangements of medical requirements at future SOLGB games.

Patients presenting with emergency conditions during August to November 2009, and admitted to medical wards, including intensive care units, were enrolled. The time each patient spent in the ED, and other parameters were recorded. The primary outcome was the association between lead-time and hospital mortality. The secondary outcome was the association between lead-time and delta Modified Early Warning Score (MEWS) (MEWS at ward – MEWS at ED).

381 cases were analysed. The overall mortality rate was 8.9%. By univariate analysis, the significant factors associated with mortality outcome were lead-time, ECOG (Eastern Cooperative Oncology Group) score, MEWS at ED, delta MEWS and sepsis. By multivariate analysis, the remaining significant factors were MEWS at ED, delta MEWS and sepsis. There was no significant relationship between delta MEWS and lead-time. In a sub-group of patients admitted to intensive care units, however, there was a positive correlation between lead-time and delta MEWS.

MEWS, delta MEWS and sepsis were predictors of hospital mortality in emergency medical patients. Lead-time was not associated with mortality, which could be due to benefits of various treatments initiated in the ED. In patients requiring intensive care, however, the longer lead-time probably led to higher MEWS and mortality.

Records of trauma patients admitted to a state emergency department (ED) in eastern Turkey, between January 2006 and December 2007 were reviewed and data were analysed based on gender.

In total, 5379 (87.0%) men and 806 (13.0%) women, totalling 6185 patients, were assessed. Mean age was 26.5 (1 month – 80 years) years for men and 24.7 (2 month – 81 years) years for women. Men comprised 90.2%, 81.3% and 77.3% of the patients injured by assault, motor vehicle incidents and falls, respectively. Women comprised a significantly larger share of suicide attempts (70.8%) than men. Of the men injured, 90.6% were discharged after treatment in the ED. The per cent of hospitalised women (5.8%) was increased compared with the per cent of hospitalised men (p=0.011). There was a higher frequency of transfer among women (8.6%) when compared with men (p<0.001). Women had a mortality frequency of 1.2%, which was similar to the mortality per cent calculated for men.

Men were at an increased risk for trauma, especially assault. The percentage of women injured and admitted to the ED due to assault was low compared with statistics reported in the literature. However, assault is the most common cause of trauma among women. The high per cent of hospitalisation and transfer among women may indicate that women are exposed to more severe trauma, and therefore experience increased morbidity compared with men.

This was a prospective cohort study of faculty supervising students completing an EM clerkship. Student schedules were aligned to maximise continuity with faculty. Faculty completed surveys prior to the start of the study and again at the end of the study period.

Faculty generally indicated a favourable opinion regarding continuity with students. Significant change was noted in two survey questions from pre- to post-intervention: faculty reported higher motivation to teach and felt the students' learning experience was better with improved continuity.

EM faculty express theoretical optimism regarding the value of improved continuity between teacher and learner. This positive sentiment persisted after actual experience with students on a shift allocation model that aligns faculty and student schedules.

This was a qualitative study involving a single emergency medical system. Data were gathered through focus groups and semi-structured interviews. Participants were purposively sampled from patients transported by ambulance to hospital with a painful condition during the past 6 months, ambulance service and emergency department (ED) clinicians. Interviews were audiotaped, transcribed and thematic analysis was conducted.

55 participants were interviewed: 17 patients, 25 ambulance clinicians and 13 ED clinicians. Key themes included: (1) consider beliefs of patients and staff in pain management; (2) widen pain assessment strategies; (3) optimise non-drug treatment; (4) increase drug treatment options; and (5) enhance communication and coordination along the pre-hospital pain management pathway. Patients and staff expected pain to be relieved in the ambulance; however, refusal of or inadequate analgesia were common. Pain was commonly assessed using a verbal score, but practitioners' views of severity were sometimes discordant with this. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Pre-hospital pain management could be improved by addressing practitioner and patient barriers, increasing available drugs and developing multi-organisational pain management protocols supported by training for staff.

Pain is often poorly managed and undertreated in the pre-hospital environment. The authors' findings may be used to inform guidance, education and policy to improve the pre-hospital pain management pathway.

Findings from a previous qualitative study were used to develop a self-administered questionnaire measuring individual, environmental and system factors, along with staff attitudes towards using IT. The questionnaire was sent to 535 staff working in three English EDs. Simple linear regression was used to examine the relationship between each potential predictor and user attitude, and multiple regression was used to identify the most important predictors.

Completed questionnaires were returned by 362/535 participants (68%). The factors with the strongest positive association with staff attitudes towards using IT were the perceived individual impact of technology (r²=39%, p<0.001), perceived usefulness (r²=7%, p<0.001), perceived ease of use (r²=2%, p=0.006), perceived subjective norms (r²=1%, p=0.013) and computer experience (r²=1%, p=0.034).

The perceived individual impact of technology is the most important factor in determining ED staff attitude towards using IT. The ED staff are more likely to view using IT systems positively if they can see direct individual benefits arising from their use.

A prospective audit over 2 years was conducted. Patients were considered for discharge by a reporting radiographer-led service if they were >5 years old, attended the hospital ED between 9:00 and 17:00, Monday to Friday, had an injury below the elbow in the upper limb or below the knee in the lower limb that required an x-ray, and were able to be discharged home without further medical intervention. Outcomes of interest were overall waiting times, accuracy of diagnosis and re-attendance at the ED within 28 days.

Between July 2006 and June 2008, 497 patients met the inclusion criteria and were discharged home by the radiographer-led service, and 2632 were discharged home using standard practices. Overall waiting times were >20 min quicker for the radiographer-led service at 100.9 min. The false negative rate was reduced from 2.09% to 0.2%, and re-attendance at the ED within 28 days for the same injury was reduced from 3.27% to only 0.4% for radiographer-led discharge.

The service reduced waiting times and re-attendance rates while improving the accuracy of diagnosis. The efficacy of such services should be further studied in relation to more complex patient groups.

Young adolescents (<18 years) with initial PSP were treated with aspiration (control group), small-bore pigtail catheters or large-bore catheters. Treatment was determined on a case-by-case basis with parental consultation. Success rate, recurrence rate (within 12 months), duration of hospital stay, duration of catheter insertion, and complications were analysed.

There were 41 patients treated: aspiration, n=8; small-bore pigtail catheters, n=10; large-bore catheters, n=23. Demographic and baseline clinical characteristics were similar between groups. The success rates were 50.0% and 65.2% in the small-bore pigtail and large-bore catheter groups, respectively. Corresponding recurrence rates were 20.0% and 56.5%. There was no difference between the small-bore pigtail and large-bore catheter groups in the duration of hospital stay in patients for whom treatment was successful; however, the duration of catheter insertion was significantly shorter in the small-bore pigtail catheter group compared with the large-bore catheter group in patients for whom treatment was successful (p<0.05). There were no major complications in either catheter treatment group and few minor complications (small-bore pigtail catheter, n=2; large-bore catheter, n=4).

The findings suggest that small-bore pigtail catheters may be as effective as large-bore catheters for the initial treatment of PSP in young adolescents.

Retrospective analysis of publicly available ‘total time spent in accident and emergency’ data from Department of Health.

Patients attending emergency departments (EDs) in England between October 2002 and September 2011. In 2005, the government set an operational standard that 98% of patients should wait <4 h in ED. In June 2010, the government announced that the operating standard would change to 95% immediately.

Percentage of patients waiting <4 h (weekly and quarterly), and total number of patients waiting >4 h.

The average percentage of patients waiting <4 h fell from 98% to 95% almost immediately following the operational standard change. Consequently, between October 2010 and September 2011, approximately 383 000 additional patients in England EDs waited in excess of 4 h than had the 98% standard been attained. The emergency care system appears to have been stabilised at this new level.

The policy change for waiting times in EDs in England has resulted in the process of emergency care in England adjusting to the new operational standard of 95% of patients waiting <4 h. As a result, more patients are waiting >4 h to receive the care they need; consequently, outcomes are likely to suffer.

31 major trauma patients with an injury severity score >15 and the necessity of a MDCT scan (standard of reference) were enrolled prospectively to this study, and additionally examined with a HCU, according to ‘focused assessment with sonography for trauma’ principles for the assessment of organ lacerations and free intra-abdominal fluid. The HCU device employed was of the latest generation. Statistical analysis was performed using PASW V.18.

Four patients were diagnosed with free intra-abdominal fluid (prevalence 12.9%). HCU showed a sensitivity and specificity of 75% and 100%, respectively. Positive predictive value and negative predictive value were 100% and 96%, respectively. Five patients had organ lacerations (prevalence 16.1%). In these cases, the HCU was able to detect organ lacerations with a sensitivity and specificity of 80% and 100%, respectively. Therefore, a positive predictive value and negative predictive value of 100% and 96%, respectively, were calculated.

In major trauma patients, examination with HCU according to the ‘focused assessment with sonography for trauma’ principles for the diagnosis of organ lacerations and free intra-abdominal fluid is a reliable and rapid alternative to MDCT scans and can help save precious time in emergency situations, and should, additionally, be evaluated in the pre-clinical workflow.

This study was a cross-sectional, web-based survey. The study subjects were the faculty of EDs from 96 teaching hospitals. The questionnaire was posted on an internet site, and the participants were requested that the questionnaire be answered by email and telephone in May 2009.

The questionnaires were completed by 67.7% of the participants. Only 20% of EDs had institutional PSA guidelines, 21.5% of those had discharge criteria and 13.8% of EDs had a discharge instruction form. Residents were administered PSA at 76.9% of EDs. The airway rescue equipment was near the area where PSA was performed in 76.9% of EDs. The most commonly used medication for both diagnostic imaging and painful procedure was oral chloral hydrate (87.7%, 61.5%). In 64.6% of EDs, patients were monitored. In only 21 cases, EDs (50.0%) monitored the patients to recovery after PSA or discharge.

Current PSA for paediatric patients have not been appropriately applied in Korea. Unified PSA guidelines were rare in the hospitals surveyed, and many patients were not monitored over an appropriate duration, nor did they receive adequate medications for sedation by the best trained personnel. Therefore, the national PSA guidelines must be developed and implemented as early as possible.

To understand why people volunteer for, and continue to be active in CFR groups.

Qualitative study, using focus groups of CFRs. Five focus groups were conducted, with a total of 35 participants.

Ideas of altruism and a sense of community were found to be important to volunteers, though motives were complex and individual. Many volunteers had some sort of prior experience relevant to the CFR role, either as health professionals or first-aiders.

Though volunteers' motives had some commonalities with the limited literature, there were issues that were unique to the CFR context. The flexibility and autonomy of CFR volunteering was particularly attractive to volunteers. It remains to be seen how sustainable the CFR model is.

Data on all cases of opioid overdose treated by the medical emergency care unit between 1994 and 2003 were recorded prospectively. Risk factors for death within 48 h after initial medical emergency care unit contact were analysed in a multivariable logistic regression analysis.

The authors recorded 4762 episodes of opioid overdose, covering 1967 unique identified patients. A total of 78 patients (8.4%, 95% CI 7.0 to 10.4) died within 48 h in the period 1999–2003, and 85% (66/78) of these had cardiac arrest and died. The authors found age >50 years and overdose during the weekend significantly associated with 48-h mortality. Gender, former episodes of opioid overdose, time of the day, month or year were not significantly associated with increased mortality.

The author found a 48-hours mortality of 8.4%. Advanced age and opioid overdose in the weekends were significant risk factors. Release on scene after treatment was associated with a very small risk.

Questionnaire study; convenience sample.

200 questionnaires were completed. 37.5% of participants were male subjects; mean age was 40.4 (SD 16.9; range 15–85) years. There was no difference in the number willing to discuss OD after brainstem death in intensive care unit compared with circulatory death in the ED (72% vs 72%; p=0.146). The majority were willing to discuss OD soon after ED death after cardiac arrest (106; 54%). 41 (21%) were not willing and 43 (22%) had no strong views (n=198). Organ preservation procedures (groin tube insertion, continuation of mechanical cardiopulmonary resuscitation and continuation of ventilator) were acceptable to between 48% and 57% of respondents if performed before discussion with family increasing to an acceptability of between 64% and 69% after discussion with family. One in four respondents felt these procedures were not acceptable regardless of the timing of discussion with family and some felt these procedures were more acceptable if the patient was a registered organ donor. 122 (61%) patients wished to donate their organs after death but only 59 (30%) were registered donors.

(1) The majority of patients and their relatives are not averse to OD being discussed shortly after ED death. (2) Organ preservation procedures are acceptable to many. Prior discussion and prior organ donor registration may improve acceptability.

A prospective double-blinded observational pilot study requiring students to interpret the conscious state of four adult patients using the GCS by viewing a simulation DVD package.

There were 137 students who participated in the study, of whom 65% (n=87) were female students. The results demonstrated that undergraduate paramedic students were unable to accurately interpret a number of patient conscious states with only 20% and 37% of students able to accurately identify the GCS of patients 2 (GCS=12) and 3 (GCS=7). The motor component of the GCS appeared to be the component where the least accurate interpretation occurred, with only 47% of students being able to accurately identify the criteria that patient 3 displayed. Participants were however able to accurately interpret the GCS of both patient 1 (GCS=14) (86%) and patient 4 (GCS=15) (92%).

This pilot study demonstrates that undergraduate paramedic students from an Australian university were unable to accurately interpret a patient's conscious state if their GCS score was <14. These findings have provided academic staff with important information for considering alternative teaching and learning strategies and approaches in conscious state assessment in current paramedic curricula.

A retrospective review and comparison of 96 cases predating the introduction of the ARF and 90 cases immediately following its introduction were performed.

The introduction of the ARF yielded significant improvement in the recording of selected data points: difficult airway indicators (p<0.0001), Cormack–Lehane grade of laryngoscopy at first attempt (p<0.0001), documentation of confirmation of tracheal intubation with end-tidal carbon dioxide monitoring (p=0.015) and recording of intubator's details (p<0.0001).

This study validates the use of a dedicated ARF for the improvement of documentation and data collection related to prehospital rapid sequence intubation when compared with post-event extraction of data from a generic case-record.

Sixty-eight medical interns who participated in a training programme for endotracheal intubation using the DE and ML were recruited to the randomised crossover trial 1 week after completing the training programme. In the trial, they used both the DE and the ML to perform intubation on a manikin wearing a semirigid neck collar. The time required to view the vocal cords and to complete intubation, successful endotracheal intubation, modified Cormack–Lehane classification (CL grade) and dental injury were recorded and analysed.

The mean (SD) time to view the vocal cords was significantly shorter with the DE than with the ML (10.0 (7.0) vs 20.8 (18.9) s; p<0.0001). There were higher rates of CL grades 1 and 2a (69.1% and 22.1%) using the DE than with the ML (10.3% and 14.7%). All 68 participants had a higher rate of successful endotracheal intubation using the DE than using the ML (68 (100%) vs 47 (69.1%); p<0.0001). It took less time to complete endotracheal intubation with the DE than with the ML (p<0.0001).

In patients with cervical spine immobilisation by a semirigid neck collar, the DE may be a more effective device for endotracheal intubation than the ML.

The purpose of the study was to identify the sensitivity and specificity of CT scan and angiography in detecting ongoing internal bleeding.

Consecutive patients who sustained torso trauma and subsequently underwent CT scan and angiography were included in this study. Data reviewed included clinical information, CT scan and angiography readings. Extravasations of contrast from CT scan and/or angiogram were considered positive for ongoing internal bleeding.

From January 2002 through July 2007, 113 adult trauma patients sustaining torso trauma underwent CT scan of chest or abdomen followed by angiography. Sixty-six patients were negative for extravasation from either of the tests. Twenty-four of 35 patients had both positive CT scans and angiograms. Eleven patients with positive CT scans did not have bleeding on angiogram. Similarly, 12 out of 36 patients with positive angiograms did not show any extravasation of contrast on CT scan. Both modalities had a specificity of 100% based on clinical definition. The sensitivities of CT scan and angiogram were 74.5% and 76.6%, respectively. They were not significantly different (p=0.95). The negative predictive values for CT and angiogram were 84.6% and 85.7%. They were not significantly different (p=0.95) either. When CT scan was used alone, 25.5% of bleeding patients were missed.

The sensitivity of CT scan and angiography at detecting ongoing bleeding was around 75% across the torso injury spectrum.

A descriptive paper-based questionnaire collecting demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions was administered to undergraduate paramedic students.

The mean score was 39.5% with only 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%.

This study suggests undergraduate paramedics have deficiencies in performing accurate calculations with conceptual errors indicating a fundamental lack of mathematical understanding.

Cross-sectional internet-based survey.

Survey invitations were sent via email to 98 registered ALS paramedics in the Johannesburg area. The survey questionnaire was created by combining the Copenhagen Burnout Inventory (CBI) with numerous distractor questions. Burnout was defined as a CBI score >50. Descriptive analysis was performed and results subjected to Chi-square testing in order to establish dependencies between burnout scores and demographic factors.

A 46% (n=45) response rate was obtained. Forty responses were eligible for analysis. 30% of these respondents had total burnout according to their CBI score, while 63% exhibited some degree of burnout in one of the CBI subcategories. The results of the subcategory analyses showed that 23% of respondents experienced burnout in the patient care-related category, 38% experienced burnout in the work-related category and 53% experienced burnout in the personal burnout category. There were no statistical differences in the burnout scores according to gender (p=0.292), position held (p=0.193), employment sector (p=0.414), years of experience (p=0.228) or qualification (p=0.846). Distractor questions showed that paramedics feel overworked, undervalued, poorly remunerated and unsupported by their superiors.

This sample of Johannesburg-based paramedics had a greater prevalence of burnout compared with their international counterparts. Further research is needed to identify the true extent of this problem.

To determine whether early MRI in suspected occult scaphoid fractures is more clinically and cost effective than conventional management with immobilisation and reassessment.

All patients presenting to the Emergency Department at a district general hospital with a suspected occult scaphoid fracture were randomised into two groups, MRI (early scan of the wrist, discharged if no injury) and control (reassessment in clinic).

84 patients were randomised into MRI (45) and control (39) groups. There were no baseline differences apart from greater dominant hand injuries in the MRI group (62% (26) vs 36% (14), p=0.02). There were three (6.7%) scaphoid fractures in the MRI group and four (10.3%) in the control group (p=0.7). More fractures (15.6% (7) vs 5.1% (2), p=0.9) and other injuries were detected in the MRI group who had fewer mean clinic appointments (1.1±0.5 vs 2.3±0.8, p=0.001) and radiographs (1.2±0.8 vs 1.7±1.1, p=0.03). Mean management costs were £504.13 (MRI) and £532.87 (control) (p=0.9). The MRI group had better pain and satisfaction scores (not significant) with comparable time off work and sporting activities.

Early MRI in occult scaphoid fractures is marginally cost saving compared with conventional management and may reduce potentially large societal costs of unnecessary immobilisation. It enables early detection and appropriate treatment of scaphoid and other injuries.

1. Since the patient has left lower quadrant pain of subacute onset, the differential diagnosis should include diverticulitis, renal colic or testicular pathology. Also on the differential diagnosis, although less likely, would be prostatitis, pyelonephritis, atypical appendicitis and cancer.

2. The patient should undergo a thorough physical examination including a testicular and...]]> 2012-04-05T02:01:46-07:00 info:doi/10.1136/emermed-2011-200868 hwp:master-id:emermed;emermed-2011-200868 British Association for Accident and Emergency Medicine 2012-04-05 Short answer questions (SAQs) http://emj.bmj.com/cgi/content/short/emermed-2012-201336v1?rss=1 A man presented to the emergency department with a stab wound to his right upper quadrant. His vital signs were in the normal range. Examination revealed a 1.5 cm wound at the junction of the subcostal margin and the linea semilunaris. There was localised peritonitic tenderness. Lactate was elevated at 4.3 mmol/l.

FAST ultrasound (focused assessment with sonography for trauma) was performed. Initial perihepatic imaging did not reveal fluid in Morison's pouch (figure 1). In the course of this imaging, a thin anechoic strip was noticed around the gallbladder (figure 2). This pericholecystic fluid collection rapidly increased in size on serial FAST examination after 5 min (figure 3). He went on to have emergency CT (figure 4) prior to surgery.

The patient underwent midline laparotomy with repair of liver laceration and gallbladder. Leakage of bile and blood around the gallbladder was found during surgery. He had an...]]> 2012-04-04T02:02:36-07:00 info:doi/10.1136/emermed-2012-201336 hwp:master-id:emermed;emermed-2012-201336 British Association for Accident and Emergency Medicine 2012-04-04 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2012-201177v1?rss=1 Introduction

The scaphoid bone is the most commonly fractured carpal bone. MRI is now recognised to be more sensitive and specific than serial plain films in the diagnosis of occult scaphoid fracture. What is not known is whether it is safe to discharge, without follow-up, those with a normal limited extremity MRI. The primary objective of this study was to determine whether a normal limited scaphoid MRI safely excludes clinically significant injury. The secondary objectives were to determine morbidity and patient experiences of those without fracture on MRI.

This is a cohort study with retrospective case note review and a written follow-up questionnaire conducted in a South of England emergency department soft tissue review clinic.

214 limited extremity MRIs were performed between January 2006 and July 2008 for suspected scaphoid injury. 152 participants were included in the study. 122 (80%) MRIs showed no fracture. In 72 (47%), there were no traumatic findings. The most significant finding in 33 (22%) was bony bruising and joint oedema in 17 (11%). One (0.9%) clinically important injury was missed. There was significant morbidity in those with normal MRIs. Worst-case scenario analysis shows that at least 12.5% of patients with a normal MRI still had symptoms and 14% still had abnormal function a year or more after injury.

This study shows that limited extremity MRI can safely exclude clinically important injury. Significant symptoms do persist, however, for many patients with a normal MRI.

A retrospective, cohort study was performed reviewing patients seen in the emergency department between 2005 and 2008 for the three most common surgical complaints encountered before the systems change: head trauma, testicular pain and abdominal pain. Outcomes include misdiagnoses, consultation rates, dispositions, imaging, interventions and surgeries.

A total of 2415 patient visits were included. Emergency physicians saw more patients (1388 vs 1027) and obtained more consultations (25.6% vs 8.1%) than surgeons. Patients triaged directly to surgeons were more likely to be admitted to the hospital (10.3% vs 7.6%), undergo urgent interventions (9.5% vs 6.7%), undergo surgery (8.0% vs 4.8%), have more radiographic images to evaluate head trauma (12.1% vs 5.3%), be misdiagnosed (1.0% vs 0.3%) and have more plain films for abdominal pain (3.1% vs 1.3%). There is an overall trend towards fewer missed diagnoses by emergency physicians (0.3% vs 0.9%), but this difference is only statistically significant in the abdominal pain subset analysis (p=0.032, combined data p=0.052).

The single provider model of emergency medicine where emergency physicians manage all patients presenting to the emergency department appears to be a safe and efficient model of emergency medical care.

National survey of UK ambulance services.

11/13 Ambulance services (84.6%) participated in this national survey.

This survey has highlighted the need for robust evidence to inform policy, service and practice development to improve the care of this vulnerable population.

The study aims at analysing the impact of the geriatric consultation service on the acute medical admission, and to study the characteristics and outcome of geriatric patients.

Retrospective study. Patients who received geriatric consultations during 1 January 2009 to 1 March 2011 were enrolled. The demographic information, diseases case mix, venue of discharge, clinical severity, community nursing service referrals and adverse outcomes were retrieved and analysed. The incidence of adverse outcomes under the presence of each factor was studied.

2202 geriatric patients were referred. Their age ranged from 45 to 99 (mean 79.91, SD 7.45, median 80). These cases were categorised into: (1) chronic pulmonary disease (n=673; 30.6%), (2) debilitating cardiac disease (n=526; 23.9%), (3) geriatric syndromes (n=147; 6.7%), (4) neurological problems (n=416; 18.9%), (5) diabetes-related problems (n=146; 6.6%), (6) terminal malignancy (n=39; 1.8%), (7) electrolyte or input/output disturbance (n=137; 6.2%), (8) non-respiratory infections (n=36, 1.6%) and (9) others (n=82; 3.7%). Acute medical admission was evaded in 84.7% of all consultations with 1039 (47.2%) patients discharged home and 825 patients (37.5%) admitted to convalescent hospital. The incidence rate of adverse outcomes was 1.6%.

Programme ‘We Care’ provided comprehensive geriatric assessment to suitable geriatric patients, resulting in an effective reduction of acute geriatric hospital admission.

A single-centre prospective observational cohort study was conducted in the ED of a medium-sized teaching hospital. Charted vital-sign data were collected from adults attending the resuscitation room, majors or observation ward. These data were examined in parallel with clinical notes to identify ‘escalation’ events. For each set of vital signs, the authors calculated the T&T score retrospectively.

Data from 472 patient episodes (2965 sets of vital signs) were examined. 85.8% of patients had at least one full set of observations (CEM standard) and 60.6% had at least one T&T score documented. However, only 34.5% of observation sets had a corresponding T&T score. 20.6% of T&T score totals (1024) were incorrect, potentially preventing a ‘trigger’ from being recognised. 204 patient episodes had at least one recorded escalation. Physiological escalations were associated with vital-sign scores that met the triggering thresholds (98/104), while patients who had non-physiological escalations or no escalations were more likely to have scores below the triggering thresholds (88/100). Only 26.9% of physiological escalations were associated with a documented T&T score above the triggering threshold. Retrospective completion of the charts increased that figure to 94.2%.

T&T in the ED is challenged by poor completion rates and numerical errors made during score calculation. However the potential for recognition of a deteriorating patient should not be ignored. The future work of the authors intends to evaluate an electronic system for automatically calculating T&T scores within the ED environment.

A prospective, multicentre, observational study enrolled patients undergoing evaluation for possible MI. Blood samples at presentation and 2 h later were analysed for myoglobin, creatinine kinase-MB, troponin-I and B-natriuretic peptide. Thrombolysis in Myocardial Infarction (TIMI) score and National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline for acute coronary syndrome were used to determine clinical risk. Primary outcome was MI diagnosed at index presentation. Secondary outcome was composite of all-cause mortality, MI and previously unplanned coronary revascularisation within 30 days.

1758 patients were recruited. 168 (11%) of 1501 with data sufficient for analysis had MI, and 223 (14%) of 1620 had a secondary outcome. SMB sensitivity and specificity were 0.90 (95% CI 0.84 to 0.94) and 0.41 (95% CI 0.39 to 0.44) for MI. For 30-day outcome, SMB sensitivity and specificity were 0.84 (95% CI 0.78 to 0.88) and 0.41 (95% CI 0.39 to 0.44), compared with standard 8–12 h troponin sensitivity and specificity of 0.79 (95% CI 0.73 to 0.84) and 0.96 (95% CI 0.95 to 0.97). Combined with risk scores, SMB had sensitivity and specificity for MI of 0.99 (0.96 to 1.00) and 0.11 (95% CI 0.09 to 0.12) for TIMI score 0, compared with 0.98 (95% CI 0.94 to 0.99) and 0.31 (95% CI 0.29 to 0.34) for NHF/CSANZ low/intermediate risk groups.

SMB alone is not sufficiently sensitive to exclude MI. Combined with risk scoring, SMB appears to identify patients at lower risk. This requires prospective validation.

A web-based questionnaire was sent to all hospital EDs in Sweden (N=66).

A total of 46 out of 66 (70%) heads of EDs completed the questionnaire. The results show that most of the EDs are prepared to care for women and children who are victims of violence. However, there seems to be a lack of preparedness to care for other groups of patients, such as victimised men. Very few EDs have routines to identify victims of violence among patients. Results also indicate that nurses play a key role in the care for victims of violence; however, family members are rarely included in care.

A lack of general preparedness in EDs to care for all victims of violence, regardless of gender and age, can lead to many patients not receiving appropriate care and treatment. To correct this there is a need to implement guidelines and routines about the care for victims of violence. Further research can shed more light on which measures are needed to improve quality of care for these patients and their families.

In-depth interviews with 15 ambulance clinicians working in South London.

Interviewees identified that epileptic seizures that self-resolve present a triage challenge. They reported insufficient training and guidance available for these situations and substantial reliance on experience to direct their practice. Fears of litigation in the event of complications, pressures of public expectation and limited on-scene access to relevant patient information or appropriate alternative care pathways were reported to be significant factors influencing decisions for care for epilepsy seizures.

Ambulance clinicians reported negotiating a balance between patient safety and patient choice, when deciding whether to transport a patient with epilepsy to hospital or not. Clinician fears and the pressures and limitations of practice may result in hospital conveyance being used as a safety precaution in some instances.

Decisions regarding conveyance of patients with epilepsy in this study were substantially guided by ambulance clinician experience rather than by robust training and guidelines. This study supports the need for improved guidance that addresses this common area of practice and the development of alternative care pathways that may be used by ambulance clinicians for patients with epilepsy.

A survey was conducted of emergency departments (ED) in England and Wales regarding the acute management of patients with distal radius fractures. The study investigated the use of anaesthesia, the person performing both the anaesthetic and the manipulation, the use of resuscitation facilities and monitoring, the cast applied, the follow-up and the management of complex injuries or those in younger patients.

Surveys were conducted in 105 units, giving a response rate of 91% of ED in England and Wales. The most frequent anaesthetic types were haematoma block (50%), intravenous benzodiazepines (20%), Bier's block (17%) and a small minority using other techniques such as brachial plexus blocks (2%). Basic cardiorespiratory monitoring was variable, and 10% of trusts did not routinely monitor patients undergoing Bier's blocks or manipulation with sedatives. Only 50% of ED would manipulate comminuted fractures or fractures in young adult patients.

There are significant regional variations. The use of monitoring is highly variable and there are no consistent standards when administering potentially potent anaesthetic medications. The low percentage of units attempting reduction of complex fractures or fractures in young patients will disadvantage training in ED as well as patients. Guidelines are required to improve care, which is highly inconsistent at present.

This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from ‘on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)’ and ‘objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide’. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using ² statistics or t test.

Of the 20 512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165).

The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.

Retrospective observational study in South Korea.

An urban, academic, tertiary hospital.

Consecutive adult patients who were admitted to the medical intensive care unit via the emergency department (ED).

A newly developed EWS—the VitalPAC EWS (ViEWS), was used in the present study. Lactate level, ViEWS and HOTEL score were obtained from patients at presentation to the ED, and APACHE II, SAPS II and SAPS III scores were obtained after admission. The area under curve of each risk scoring system for in-hospital, 1-week, 2-week and 4-week mortality was compared.

151 patients were enrolled and the mortality was 42.4%. The ViEWS-L score was calculated as follows: ViEWS-L score=ViEWS+lactate (mmol/l) according to the regression coefficient. The mean ViEWS-L score was 11.6±7.3. The ViEWS-L score had a better predictive value than the ViEWS score for hospital mortality (0.802 vs 0.742, p=0.009), 1-week mortality (0.842 vs 0.707, p<0.001), 2-week mortality (0.827 vs 0.729, p<0.001) and 4-week mortality (0.803 vs 0.732, p=0.003). The ViEWS-L score also had a better predictive value than the HOTEL and APACHE II scores. The predictive value of ViEWS-L was comparable with SAPS II and SAPS III.

The ViEWS-L score performed as well as or better than the pre-existing risk scoring systems in predicting mortality in critically ill medical patients who were admitted to the medical intensive care unit via the ED.

The authors undertook a prospective, monocentric, randomised, double-blind, placebo-controlled, parallel-group study, using an intent-to-treat analysis. Patients admitted to the emergency department for suspected hyperalgesic (evaluated with a visual analogue scale (VAS)) renal colic were enrolled in the study. They were administered an initial treatment of ketoprofen before being randomly assigned to either the placebo or nefopam group.

Thirty patients admitted to the emergency department were enrolled in the study. Morphine analgesia was necessary for 10 patients (66.6%) (95% CI 40% to 90%) in the nefopam group and 8 (53.3%) (95% CI 30% to 80%) in the placebo group, with no statistically significant difference found (difference 13.3%, 95% CI –51% to 24%). The time needed to achieve adequate analgesia in the case of morphine titration was 8.3 min (95% CI 4.2 to 12.5) in the nefopam group and 9 min (95% CI 2.7 to 15.3) in the placebo group, with no statistically significant difference (difference 0.7, 95% CI 7.25 to 8.58).

This study did not reveal any significant difference between nefopam and placebo. This may be due to lack of statistical power or lack of effectiveness.

http://ClinicalTrials.gov ID number NCT00639574.

A 10-year retrospective case review of all adult hangings (aged ≥16 years) associated with OHCA, was conducted using data from the Victorian Ambulance Cardiac Arrest Registry.

Between 2000 and 2009, the emergency medical service (EMS) attended 33 178 adult OHCAs of which 1321 (4%) had hanging as the aetiology. The median age (IQR) of hanging-associated OHCA cases was 39 (29–51) years and 1162 were men (88%). The first recorded rhythm by EMS was asystole seen in 1276 (75.5%) patients, pulseless electrical activity (PEA) in 38 (13.4%) cases and ventricular fibrillation in 7 cases (0.5%). EMS attempted resuscitation in 208 (15.7%) patients of whom 61 (29.3%) achieved return of spontaneous circulation (ROSC) and were transported, and 7 (3.3%) survived to hospital discharge. Hanging-associated OHCAs were younger (median (IQR) 38 (29–51) years versus 74 (61–82) years, p<0.001), less likely to have a shockable rhythm (0.5% vs 17.2%, p<0.001), receive bystander cardiopulmonary resuscitation (14.1% vs 25.5%, p<0.001) or an attempted resuscitation by EMS (15.7% vs 36.1%, p<0.001) compared with OHCA cases with an aetiology of ‘presumed cardiac’ arrest. Multivariable logistic regression identified factors associated with EMS decision to attempt resuscitation; the adjusted OR (95% CI) for ‘presence of bystander cardiopulmonary resuscitation’ was 15.8 (10.70–23.30) and for ‘witnessed arrest’ was 5.26 (1.17–23.30).

Attempted resuscitation was not always futile with a survival of 3.3%. A preventive focus is needed.

A retrospective case note review for children <16 years attending with a confirmed oesophageal coin on x-ray over a 7-year period (1 January 2004 to 31 December 2010).

89% (33/37) of coins in asymptomatic patients, who were conservatively managed, had passed spontaneously on repeat chest x-ray up to 18 h later. No patient who was discharged with a middle or lower oesophageal coin required a GA and no child who was treated conservatively developed any complications.

In the UK asymptomatic children, with no history of tracheal or oesophageal disease and a confirmed oesophageal coin on x-ray should undergo a period of observation up to 18 h. This can be safely undertaken at home, followed by a repeat x-ray in the emergency department.

To determine the sensitivity and specificity of trauma experienced and trauma inexperienced emergency physicians in detecting pelvic fractures compared with radiologists, the latter subgroup combined report being used as the gold standard.

Prospective cohort study conducted in two large teaching hospitals in central London. All participants reviewed 144 consecutive pelvic radiographs performed each as part of a ‘trauma series’ and known to have undergone concomitant pelvic CT imaging.

No statistically significant difference was found between radiologists and emergency physicians from a trauma centre in pelvic radiograph interpretation. Radiologist reporting was associated with an improved specificity compared with emergency physicians working in a non-trauma hospital (p=0.049). The study population missed 30% of fractures on plain radiography against the gold standard of CT.

The ability to interpret trauma series pelvic radiographs is comparable between emergency physicians and radiologists. If this were also true of trauma chest radiographs, then the most valuable use of the radiologist may not be the resuscitation room but in rapid reporting of more complex imaging techniques. However, plain radiography is insensitive for pelvic fracture detection compared with CT, even in expert hands.

IND was introduced to the Royal Aberdeen Children's Hospital on 24 December 2009. A retrospective case series was constructed to compare its clinical performance with its predecessor IVM. Three unexplored factors were investigated: time to opiate analgesia, the requirement for further analgesia when still in the emergency department and the effect of simple coanalgesia (eg, paracetamol/ibuprofen) on these requirements.

297 patients were eligible for the study (147 IND, 150 IVM) over a 28-month period. There was a non-significant trend to a longer median time to administration of analgesia in patients receiving IND (p=0.170). Patients who received IND were less likely to require further analgesia (p<0.001). Both groups were less likely to require further analgesia when simple coanalgesia was given (p=0.049).

The authors found no significant difference in time to administration of analgesia between agents, but a learning curve has been identified. Sustained effort should be placed on the use of simple coanalgesia. The clinical performance of IND compares favourably with IVM in children with severe pain, and it remains an appropriate preferred agent.

This was a retrospective review of EM resident physicians and MLPs in an ED low acuity area. The number of patients seen and relative value units (RVUs) generated per clinical hour worked were evaluated. A t test was used to compare resident and MLP productivity. Additionally, patients were prospectively surveyed to assess satisfaction, using survey items based on the Press-Ganey survey. Non-parametric statistics were used to analyse patient satisfaction scores.

MLPs treated 2.21 patients per hour (CI ±0.09), while resident physicians treated 1.53 patients per hour (CI ±0.08). MLPs generated 4.01 RVUs per hour (CI ±0.18) while resident physicians generated 3.14 RVUs per hour (CI ±0.18). Resident physicians generated 2.07 RVUs per patient (CI ±0.08) while MLPs generated 1.82 RVUs per patient (CI ±0.03; p<0.001). Of the 201 completed satisfaction surveys, 126 patients were seen by MLPs and 75 were seen by residents. Overall patients were highly satisfied with their ED visit. There were no differences in any survey responses based on provider type or resident level of training.

In a low acuity area of the ED, MLPs treated more patients per hour and generated more RVUs per hour than EM resident physicians. However, resident physicians generated more RVUs per patient. Patient satisfaction did not differ.

This study compares: (1) information given during discharge conversations, based on audio recordings of the conversations, with (2) accuracy of patient recall of this information, based on postdischarge interviews. During these interviews, the authors also assessed (3) amount and accuracy of information provided during treatment. Furthermore, the authors obtained (4) satisfaction ratings by physicians and patients. Data were collected for 96 patients during 20 shifts.

Sufficient information was provided in 83% of discharge conversations. Patients correctly recalled 82% of information received about diagnosis, 56% about examinations planned and 72% about follow-up treatments. Information related to medication was most prone to forgetting or distortion. Altogether, 43% of the patients left the ED correctly informed about diagnosis, planned examinations and follow-up. Patient satisfaction ratings were high (mean 4.7 on a 5-point Likert Scale) and not related to informedness of the patient.

Patients had important information deficits when leaving the ED, and information transmission needs to be improved. The physician–patient discharge conversation seems an ideal opportunity for enhancing patient informedness. Standardisation of discharge procedures and training physicians in how to ensure that patients actually understand the information provided are needed.

Data were examined from 81 consecutive trauma patients requiring cervical spine radiography. EAST guidelines were applied retrospectively to this cohort in order to define guideline compliance. An additional cohort assessment was conducted addressing the accuracy and adequacy of the formal institutional reports associated with these radiographs.

99% of patients undergoing a full cervical trauma series had at least one inadequate initial image. Of these, 85% had at least one inadequate lateral or peg view (of which 26% did not have repeat radiographs performed). Over one-third of all trauma patients left the emergency department with inadequate cervical spine imaging (incomplete cervical spine series or inadequate films). From the institutional reporting perspective, only 27% of all inadequate initial and repeat lateral or peg views were subsequently explicitly reported as being inadequate.

These findings call into question current practice. Clearly, multiple confounders exist in the context of process variability in a heterogeneous population such as that attending an emergency department. This study offer solutions to address this problem.

The study conducted from December 2010 to August 2011 involved 48 volunteers who were students in the emergency medical technician course. The authors let volunteers practice OP and AP as a crossover design. The authors monitored the simulated mean arterial pressure (MAP) generated during a 5-min chest compression. The fatigue level of the volunteers after the chest compression was evaluated with the Likert scale.

There were no significant differences in MAP between the dominant hand and the non-dominant hand as the lower thumb of OP. Significant differences were observed in simulated systolic blood pressure, MAP and simulated pulse pressure between OP and AP at 1, 2, 3, 4 and 5 min. There were no significant differences among the changes in heart rate, respiratory rate and end-tidal CO₂ during a 5-min chest compression by OP and AP. The Likert scale scores (1 no fatigue to 5= extreme fatigue) during the 5-min chest compressions were higher in AP than in OP at 2, 3 and 5 min.

Higher intrathoracic pressures were achieved by OP in this study. However, further studies are needed to validate these effects of overlapping thumbs technique in infant cardiopulmonary resuscitation, not manikin.

A group-level quasi-experimental trial comparing the St. Louis Veterans Affairs Medical Center emergency department (1) before intervention, (2) after institution of provider in triage, and discrete event simulation (DES) models of similar (3) ‘before’ and (4) ‘after’ conditions. The outcome measures were daily mean LOS and percentage of patients with LOS >6 h.

The DES-modelled intervention predicted a decrease in the %6-hour LOS from 19.0% to 13.1%, and a drop in the daily mean LOS from 249 to 200 min (p<0.0001). Following (actual) intervention, the number of patients with LOS >6 h decreased from 19.9% to 14.3% (p<0.0001), with the daily mean LOS decreasing from 247 to 210 min (p<0.0001).

Physician and mid-level provider coverage at triage significantly reduced emergency department LOS in this setting. DES accurately predicted the magnitude of this effect. These results suggest further work in the generalisability of triage providers and in the utility of DES for predicting quantitative effects of process changes.

A questionnaire was developed in conjunction with the TSC into nine parts covering all aspects of preparation for and experience of sitting the FCEM. Email addresses of those trainees who had sat the FCEM examination in 2006 and 2007 were provided by the CEM and questionnaires were sent electronically to recipients. Responses were collated and analysed using Microsoft Excel.

There was a response rate of 42% (86/203), of whom about three-quarters felt well prepared for the FCEM. The most highly valued resources for exam preparation were practice questions, private study and small group work. A yearly mock FCEM examination was felt to be important by those who had such access and local trainer involvement in exam preparation was perceived significant for success.

Training programmes should make sure that facilities and expertise are available at a local level to allow trainees to have access to everything that is considered important in order to pass the FCEM.

Algorithms with a decision aid for triage with minimum agreed descriptors were developed to triage two pregnancy conditions (pre-eclampsia and antepartum haemorrhage). Triage documentation was then audited before (n=50) and after (n=50) a triage education programme which introduced algorithms for both conditions. Significant differences were examined using ² test with significance set at p<0.05.

The quality of documentation of specific clinically significant symptoms of pre-eclampsia improved considerably, including the presence of headache from 58% pre-education to 80% post-education (p=0.002), visual disturbances from 58% to 90% (p<0.001), epigastric pain from 24% to 80% (p=0.002) and the presence of fetal movements from 62% to 90% (p=0.001). Documentation of descriptors for vaginal bleeding >20 weeks gestation improved for estimation of blood loss from 54% to 86% (p<0.001), patient ‘appearance’ from 32% to 62% (p=0.003) and, importantly, descriptions of patient's own assessment of their well-being from 8% to 28% (p=0.009).

The introduction of triage education and condition-specific decision aids for triage markedly improved triage assessment and documentation. The application of algorithms may reduce clinical risk resulting from suboptimal triage of pregnant women presenting to EDs.

A systematic attempt was made to contact all relief actors within the health care sector involved in the 12 January through 12 February 2010 FFH deployment. This was done using an email-based questionnaire and a web survey. In addition, the authors undertook a literature review using PubMed and the Google search engine between March 2010 and May 2011. The authors contacted key informants and agencies identified by direct observations in the field by email or phone.

A total of 44 FFH were identified. The first FFH was operational on day two post-earthquake. The number of FFH beds peaked at about 3300 on day 17 post-earthquake. During the first month, the authors estimate that FFH conducted no more than 12 000 major surgical operations. While 25% of the FFH adhered to either WHO/PAHO first essential deployment requirements, none followed both requirements of WHO/PAHO. Compared with the 2005 earthquake in Pakistan, twice as many FFH provided medical care, resulting in three times more FFH beds.

The present study suggests that more FFH were sent to Haiti than to any previous sudden-onset disasters, but due to lack of data and transparency it remains impossible to determine to what extent did the first wave of FFH do any good in Haiti.

The authors retrospectively analysed 55 cases with DIDRs at paediatric emergency department (PED) in a 5-year period.

The mean age of the patients was 145.07±56.30 months, and of the 55 cases, 28 cases (50.9%) were boys. Antiemetics and antipsychotics were the most common causes of DIDRs. 35 (70%) patients developed DIDRs at therapeutic doses. Treatment side effect was the most common cause of the DIDRs (78.2%). The most common DIDRs were abnormal postures of the head and neck (56.6%). Laryngospasm was observed only in four cases (7.3%) that used either antipsychotics or psychostimulants. 51 (92.7%) children were treated with parenteral diphenhydramine successfully.

Dystonia is a common side effect of certain drugs, even when therapeutic doses are administered. Although the most common DIDRs were abnormal postures of the head and neck, rare life-threatening conditions, may develop particularly due to use of antipsychotics. In treatment, diphenhydramine could effectively be used through parenteral way to eliminate the cholinergic effects of those drugs. However, the easiest and the safest way to prevent the development of DRs is to avoid unnecessary drug usage. In conclusion, physicians should be aware that antiemetic and antipsychotic drugs are associated with DRs in normal doses and that those drugs should be prescribed with a correct indication.

Prospective study of all documented emergency department (ED) ultrasound scans. Results were extracted from written paper reports and/or electronically saved images. Details of scan date, time, type of scan, grade of operator, supervision status (whether supervised by a level 1 competent scanner) and whether the scan was clinical (performed or supervised by a level 1 operator) or training, were recorded. EU scans were reviewed for quality (internal quality assurance) and for diagnostic accuracy (external quality assurance).

Between 14 January 2009 and 4 July 2011, 626 scans were performed by 41 operators. 263 (42%) scans were completed outside of normal working hours (09:00 to 17:00). There were 251 abdominal aorta and inferior vena cava scans (40% of all scans) and 198 focused assessment with sonography in trauma scans (32%). The number of scans performed by each operator varied widely. 87 scans (14%) were supervised but the majority (459; 73%) were not. 484 (77%) scans were for training purposes, 124 (20%) were clinical scans and the majority (401; 63%) were performed by either speciality registrars (ST4-6) or specialist registrars (SpR). When the three commonest types of scans performed were analysed, eight false positives and 11 false negatives were identified. Only seven of these were deemed of poor quality and none led to poor patient outcome.

Since the acquisition of our ED ultrasound machine and the development of a quality assured training programme, on average 20 scans per month have been performed in the ED, with no known adverse patient outcomes.

A secondary analysis of a cohort study of patients presenting to the ED with potential ACS with serum creatinine measurements. Research assistants collected demographics, history, symptoms, hospital course and 30-day follow-up. Outcomes measured were in-hospital AMI and 30-day CV events (death, nonfatal AMI, revascularisation). Prespecified multivariable models included age, gender, race and cardiac risk factors and presenting electrocardiogram (ECG). We used a creatinine cut-off point of 132.6 mmol/l. Data are presented as OR and 95% CI.

3451 patients were enrolled (age, 52.9±13.2; 55% female patients; 64% black patients). There were 120 AMI during initial visit and 232 patients had 30-day CV events (43 deaths, 128 AMI, 120 revascularisations). Creatinine values were normal in 3086 (89.4%) and abnormal in 365 (10.5%) patients. In multivariable models the adjusted OR (95% CI) for the association between abnormal creatinine and AMI was 1.43 (0.88 to 2.30) and 30-day CV events was 1.57 (1.10 to 2.25). The odds of 30-day CV events were increased for patients who were older, male subjects, white, had hyperlipidaemia, hypertension or a history of CAD, or presented with an abnormal ECG.

In patients with potential ACS in the ED, renal dysfunction predicts a higher likelihood of 30-day CV events, but not an independent predictor after controlling for other risk factors. It appears to be a marker of other CV risks.

A review of the Medline, EMBASE and CINAHL databases was conducted. Articles were included if they described the use of the HDR to revert PSVT in the prehospital or emergency medical setting, the nature of the effectiveness of the HDR for PSVT or historically significant developments of HDR techniques for PSVT reversion. Articles not available in English or describing the use of HDR in animal studies only were excluded.

211 articles were identified, of which 21 were found to be relevant. These included 10 studies of HDR effectiveness in PSVT and three physiological studies of HDR effect. No standardised model of performance exists for the HDR. Elements of performance include: a cold stimulus applied to the entire face, a specific temperature of the cold stimulus, application duration, breath holding during HDR and posture assumed to perform the procedure. There are also safety and logistics issues with using the HDR in prehospital care.

The HDR represents an effective method of terminating PSVT in the hospital emergency department. Its usefulness in prehospital care requires further evaluation of the elements of the manoeuvre to determine appropriateness to this setting.

In this study, the AMS symptoms of 78 unacclimatised rescue workers for the Yushu earthquake from Beijing were recorded using the Lake Louise AMS self-report questionnaire. Heart rate and blood oxygen were recorded at rest before departure, during rest and during activity.

After ascending, resting heart rate increased from mean 75.87 bpm to 87.45 bpm and resting SpO₂ decreased from an average of 98.51% to 90.35% (both p<0.001). The mean Lake Louise AMS Score for participants was 3.1 (95% CI 2.6 to 3.6). 29 members (37.2%) met the diagnosis criteria for AMS. 16 members (20.5%) were evacuated early due to acute AMS (AMS score ≥5). Rhodiola was offered on a voluntary basis as a prophylactic measure but shown to be ineffective.

Given the ineffectiveness of prophylactic measures and the urgency of such disaster situations, it is unrealistic to mobilise rescue teams from lowland regions for immediate relief efforts. A local disaster plan specific to plateau earthquakes needs to be developed with local personnel for timely and efficient relief.

Data collectors were asked to physically locate each relevant antidote in the ED, and check whether the recommended quantity was available. If the antidote was not available in the department, the data collector located where in the hospital stocks were available. Senior medical and nursing staff were asked to specify where they believed the antidotes were stored or who they would ask if they did not know. It was then ascertained whether their source of advice would have known the location.

5 out of 6 departments returned data with an overall response rate from senior medical and nursing staff of 80%. Knowledge of common antidote locations was variable, and stocking of antidotes did not universally meet the College of Emergency Medicine recommendations.

Stocking of important antidotes should be rationalised and simplified using central locations, preferably close to the ED. Clinically important antidotes may not be available for patients when they need them. Clear guidance should be available for staff detailing the location of antidotes. There is a need for clarification around the treatment of cyanide poisoning to facilitate rational antidote stocking for this potentially lethal condition.

Anonymous web-based survey of 77 UK Emergency Medicine (EM) consultants from 28 UK EDs that see children during the period April–June 2010.

62% (48/77) of surveyed consultants responded from 21/28 (75%) EDs. All managed children post cardiac arrest. 90% (43/48) were aware of the literature concerning TH after cardiac arrest in adults. However, 63% (30/48) had never used TH in paediatric practice. All departments had at least one method of inducing TH (surface cooling; air/water blankets; intravenous cold fluid or catheters). Reasons stated for not inducing TH included no equipment available (26%; 11/42), TH not advocated by the local PICU (24%; 10/42) and not enough evidence for its use (24%; 10/42). TH was considered based on advice from the local Paediatric Intensive Care Units (68%; 17/25) or likelihood of recovery after arrest (32%; 8/25). There was strong support for a UK RCT of TH versus normothermia (85%; 40/47). The proposed RCT was felt to be ethical (87%; 40/48) with use of deferred consent acceptable (74%; 34/46).

UK EM consultants are aware of TH but infrequently initiate the therapy in children for a number of reasons. Their involvement would enable early induction of TH in EDs after paediatric cardiac arrest during a UK RCT. The authors have demonstrated the availability of suitable equipment and EM consultant support for participation in such a RCT.

Retrospective study of patients attending emergency departments of 14 acute hospitals in Hong Kong. Data were retrieved from a centralised administrative database.

Of 2 531 225 patients who attended emergency departments between 1 January 2001 and 31 December 2003, 780 444 (30.8%) were admitted to medical wards. A model derived from 2001 data shows well-calibrated admission probabilities, with an area under the receiver operating characteristic curve for probability of admission of 90.3 (95% CI ±0.11). The areas under the receiver operating characteristic curves for 2002 and 2003 validation sets were 89.9 (95% CI ±0.11) and 89.0 (95% CI ±0.12), respectively. With an averaged benchmark, reductions in medical admissions of up to 19% could be achieved, while under the most optimistic assumption, reductions of up 36% could be achieved.

A tool for benchmarking hospital medical admissions and minimising case-mix variation has been derived and validated in Hong Kong, but it requires further validation in other healthcare systems given the wide variations in admission thresholds internationally. This may be used as one potential method to evaluate the performance of emergency departments against a common standard.

An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared.

110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (²), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (²), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (²), p=0.04). No cases of serious pathology were missed using the guideline.

Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis.

A little over one-third of children will have an episode of back pain and about one-quarter seek medical attention for this chief complaint. A history of pain for more than a month, weight loss, neurological deficits, immunosuppression or rheumatological disease warrants further investigation including laboratory and imaging studies.

Spinal astrocytomas represent slightly more than half of spinal cord tumours in children, although overall they are rare causes of CNS tumours in...]]> 2012-03-02T02:01:06-08:00 info:doi/10.1136/emermed-2011-201063 hwp:master-id:emermed;emermed-2011-201063 British Association for Accident and Emergency Medicine 2012-03-02 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2012-201161v1?rss=1 A 3-year-old girl attended the emergency department (ED) complaining of shortness of breath and cough for the preceding 2 days. On examination there was marked subcostal and intercostal recession, an increased respiratory rate and coarse crepitations on the right side. Oxygen saturations were 92% on air and there was no wheeze.

A chest radiograph was obtained and at first glance appeared to show right mid-zone consolidation and bilateral pneumothoraces with clearly demarcated lung edges (figure 1). This came as a surprise, being incongruent with clinical findings.

Upon reviewing the patient, it became apparent that the overlying reservoir of the adult oxygen mask was likely to be simulating the appearance of the pneumothoraces, a fact confirmed after repeat imaging with the mask removed. The diagnosis was simply pneumonia.

Simulated pneumothorax has previously been shown to be poorly recognised in an adult population,1 and in view of the potential for serious harm,...]]> 2012-02-25T02:01:25-08:00 info:doi/10.1136/emermed-2012-201161 hwp:master-id:emermed;emermed-2012-201161 British Association for Accident and Emergency Medicine 2012-02-25 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2011-200482v1?rss=1 Objectives

The frequency and the severity of drug-related visits in emergency department (ED) make the improvement of adverse drug event (ADE) recognition a crucial issue. As part of a research project aiming to improve the diagnosis and the management of ADEs in ED, the authors conducted a pilot study whose primary objective was to assess ADE recognition by emergency physicians.

The patients presenting to the ED were included at randomised time periods between 1 October 2007 and 31 March 2008 in this prospective cross-sectional study. The primary outcome was the frequency of ADEs that were attributed to a medication-related problem by the emergency physician.

A total of 423 patients met the inclusion criteria, of which 95 experienced an ADE (22.5%; 95% CI 18.6% to 26.7%). Emergency physicians correctly attributed 33 of these cases (34.7%; 95% CI 25.3% to 45.2%) to a medication-related problem. Of the 28 cases in which the ADE was considered as a ‘direct drug effect’ (29.5%; 95% CI 20.6% to 39.7%), 16 were correctly identified by emergency physicians (57.1%; 95% CI 37.2% to 75.5%). Of the 67 cases in which the ADE was considered as a ‘drug involvement in a multifactorial pathological condition’ (70.5%; 95% CI 60.3% to 79.4%), 17 were correctly attributed (25.4%; 95% CI 15.5% to 37.5%).

ADEs are frequent in EDs and are not well recognised by emergency physicians, especially when the drug is involved in a multifactorial pathological condition.

This feasibility study assesses the usefulness of EDSSS in monitoring indicators of disease in the community. Daily counts of anonymised attendance data from six emergency departments across England were analysed by patient demographics (age, gender, partial postcode), triage coding and diagnosis codes. Generic and specific syndromic indicators were developed using aggregations of diagnosis codes recorded during each attendance.

Over 339 000 attendances were recorded (26 July 2010 to 25 July 2011). The highest attendances recorded on weekdays between 10:00 and 11:00 and on weekends between 12:00 and 13:00. The mean daily attendance per emergency department was 257 (range 38–435). Syndromic indicators were developed including: respiratory, gastrointestinal, cardiac, acute respiratory infection, gastroenteritis and myocardial ischaemia. Respiratory and acute respiratory infection indicators peaked during December 2010, concomitant with national influenza activity, as monitored through other influenza surveillance systems.

The EDSSS has been established to provide an enhanced surveillance system for the London 2012 Olympics. Further validation of the data will be required; however, the results from this initial descriptive study demonstrate the potential for identifying unusual and/or severe outbreaks of infectious disease, or other incidents with public health impact, within the community.

A prospective observational convenience study was conducted of 112 adult patients who presented to an urban county ED with AMS (Glasgow Coma Scale (GCS) score ≤14) between August 2008 and July 2009. Within the first 20 min of patient presentation to the ED, treating physicians were asked to record their best diagnostic guess of the cause of the patient's AMS and their confidence in this diagnosis. Serial hourly GCS was performed and the results of all diagnostic testing were recorded. Blinded investigators determined the final consensus diagnostic cause of the patient's AMS.

The final consensus diagnoses for AMS aetiologies were as follows: isolated alcohol intoxication 31%, other (psychotic episodes, underlying dementia) 21%, combination alcohol/other drug intoxications 18%, isolated other drug intoxications 10%, other metabolic derangements 6%, cerebrovascular accident/transient ischaemic attack 4%, seizures/post-ictal states 4%, traumatic brain injuries 3%, isolated opiate intoxications 2%, isolated benzodiazepine intoxication 1% and septic episode 1%. The emergency physician's initial diagnosis of the AMS patient correlated with the accuracy of the final diagnosis (r²=0.807). The quintiles of confidence of diagnosis were: 0–20% degree of confidence had a 33% diagnostic accuracy, 21–40% had 25% accuracy, 41–60% had 43% accuracy, 61–80% had 52% accuracy and those with 81–100% confidence of initial diagnosis had 78% accuracy. Of the 106 patients with an initial diagnosis, 52 (51%) had a head CT performed, with eight (8%) having an acute abnormality.

Early diagnoses of AMS patients are moderately accurate. Few early misdiagnoses of AMS patients were clinically relevant. Physicians' greater degree of confidence in their diagnosis correlated with greater accuracy.

The aim of this study was to characterise the physiological status and injury profile of cyclists admitted to our urban major trauma centre (MTC).

Database analysis of cyclist casualties between 2004 and 2009. The physiological parameters examined were admission systolic blood pressure (SBP), admission base deficit and prehospital Glasgow Coma Scale.

265 cyclists required full trauma-team activation. 82% were injured during a collision with a motorised vehicle. The majority (73%) had collided with a car or a heavy goods vehicle (HGV). These casualties formed the cohort for further analysis. Cyclists who collided with an HGV were more severely injured and had a higher mortality rate. Low SBP and high base deficit indicate that haemorrhagic shock is a key feature of HGV casualties.

Collision with any vehicle can result in death or serious injury to a cyclist. Injury patterns vary with the type of vehicle involved. HGVs were associated with severe injuries and death as a result of uncontrollable haemorrhage. Awareness of this injury profile may aid prehospital management and expedite transfer to MTC care. Rapid haemorrhage control may salvage some, but not all, of these casualties. The need for continued collision prevention strategies and long-term outcome data collection in trauma patients is highlighted.

The notes were retrospectively reviewed of all patients who had a CT scan requested by the emergency department over a 2-year period (January 2008 to December 2009) and from these warfarinised head injuries were identified.

82 warfarinised head injury patients were identified from 3338 requested CT scans. 12 of these patients (15%) had evidence of ICH on the CT. 72 patients had their INR checked (88%) and the RR of ICH for the INR subgroups were calculated: INR <2 (RR 1.89; 95% CI 0.65 to 5.55); INR 2–3 (RR 0.84; 95% CI 0.27 to 2.64); and INR >3 (RR 0.53; 95% CI 0.13 to 2.29). The greatest proportion of those with ICH (42%) had a subtherapeutic INR. 2 out of the 12 patients (17%) were found to have intracranial bleeding despite not meeting the criteria for a CT scan according to the NICE guidelines.

The results of the INR subgroup analysis suggest that a subtherapeutic INR may not be protective against ICH in patients with minor head injury.

186 medical and pharmacy students, never trained in basic life support (BLS) before, underwent video self-instruction training. The participants were asked to perform a BLS test on a manikin connected to a PC for 6 min immediately after training, and the quality of the cardiopulmonary resuscitation (CPR) skills was evaluated.

Women with body weights less than 56 kg were 6.29 times more likely to produce insufficient CCs than women weighing 56–62.7 kg, and 4.72 times more likely to produce insufficient CCs compared with women weighing more than 62.7 kg.

Lightweight rescuers may have difficulty achieving the full compression depth of 5–6 cm required by new resuscitation guidelines. These rescuers require special attention during CPR training, with an emphasis on correct body positioning and use of body weight for CCs.

To identify clinical and laboratory findings that may indicate OT among girls with abdominal pain.

Retrospective review of two cohorts of girls aged 5–17 years admitted to a children's hospital. Cohort 1: Girls admitted with abdominal pain from the emergency department (2008). Cohort 2: Girls with a discharge diagnosis of OT (2003–9).

Cohort 1: 325 girls were admitted from the emergency department with abdominal pain during 2008. Of these, 9 (3%) were diagnosed with OT. Cohort 2: 37 girls were diagnosed with OT during 2003–9. Clinical or laboratory features differentiating OT from all abdominal pain could not be identified. A comparison of girls admitted with confirmed appendicitis showed that OT was more likely to be associated with a mass (RR=4.2, 95% CI 1.1 to 17), and less likely to be associated with anorexia (RR=0.46, 95% CI 0.23 to 0.93), guarding (RR=0.53, 95% CI 0.34 to 0.85), an elevated C reactive protein (RR=0.32, 95% CI 0.14 to 0.83), or leucocytosis (RR=0.4, 95% CI 0.21 to 0.78). Findings were similar in girls with an admission diagnosis of ‘possible appendicitis’.

Clinical or laboratory features that would identify cases of OT among girls admitted with abdominal pain could not be identified. Some findings help to differentiate OT from appendicitis, but there is a large degree of overlap. OT is an uncommon condition, but has important management implications, and should be considered in all girls presenting with abdominal pain.

The authors performed a prospective observational study at the emergency departments of a university and teaching hospital in The Netherlands and included children attending in 2007 and 2008. The authors developed and implemented specific age-dependent modifications for the MTS, based on patient groups where the system's performance was low. Nurses applied the modified system in 11 481 (84%) patients. The reference standard for urgency defined five levels based on a combination of vital signs at presentation, potentially life-threatening conditions, diagnostic resources, therapeutic interventions and follow-up. The reference standard for urgency was previously defined and available in 11 260/11 481 (96%) patients.

Compared with the original MTS specificity improved from 79% (95% CI 79% to 80%) to 87% (95% CI 86% to 87%) while sensitivity remained similar ((63%, 95% CI 59% to 66%) vs (64%, 95% CI 60% to 68%)). The diagnostic OR increased (4.1 vs 11).

Modifications of the MTS for paediatric emergency care resulted in an improved specificity while sensitivity remained unchanged. Further research should focus on the improvement of sensitivity.

To evaluate the accuracy of the ECP's opinion when deciding whether their actions resulted in a patient avoiding attendance at an ED or avoiding hospital admission.

Over a 10-week-period in 2009, quantitative data were collected using a case review approach. Anonymised patient consultation records were independently reviewed by an ED consultant and a general practitioner. The decision as to whether the actions of the ECP resulted in the patient avoiding ED attendance or hospital admission was compared between the three healthcare professionals using descriptive statistics and values to assess inter-rater agreement.

Overall inter-rater agreement between the three healthcare professionals was =0.385 (fair agreement). The complete agreement rate on a case by case basis for all three healthcare professionals was 80.2% (138/172).

This study provides some evidence that ECPs can accurately report on whether their actions, at the time of that care episode, result in a patient avoiding attendance at an ED or avoiding a hospital admission.

Emergency department of a paediatric teaching hospital.

Retrospective study of case notes for patients attending the emergency department with a complaint of atraumatic limb pain and in whom both ESR and CRP were measured at the time of presentation. Laboratory results at the time of presentation were recorded along with the final diagnosis. Receiver operating characteristic (ROC) curves were created using the data and the optimum cut-off values for each of ESR and CRP were derived using the point of best trade off between sensitivity and specificity. Likelihood ratios for ESR and CRP individually and in combination were calculated.

259 patients were included in the study, of whom 17 were considered to have an orthopaedic infection. ROC curves revealed the best results were obtained using cut-off values of CRP >7 and ESR >12. The combination of a CRP >7 and an ESR >12 gave the best positive likelihood ratio at 6.26 (likelihood ratio 5.34 (CRP >7) vs 2.57 (ESR >12)). For ruling out disease, the combination of CRP ≤7 and ESR ≤12 also outperformed either variable individually (negative likelihood ratio 0.09 (CRP ≤7 and ESR ≤12) vs 0.34 (CRP ≤7) vs 0.18 (ESR ≤12)).

Measurement of both CRP and ESR should be considered an important aid in the investigation of atraumatic limb pain.

Fully conscious but symptomatic children ≥3 years after head injury (1997–2010) with CT performance ≤2 h since injury were included in the study. Additional exclusion criteria were set for patient selection. Evolution of clinical symptoms of patients in 24 h since injury was the focus in current study. Clinical data were extracted from standardised medical records on admission and observation charts.

Data of 1897 eligible cases were retrospectively reviewed. Traumatic brain injury (TBI) was revealed radiologically in 73 cases (3.8%). Eight cases underwent surgery. Recursive partitioning analysis identified the following factors in the CT rule: any delayed headache commenced between 4 and 10 h since injury; significantly worsening headaches present between 2 and 12 h since injury; vomiting between 6 and 12 h since injury; and headache without significant changes persisted ≥12 h since injury. It has a sensitivity of 100% (95% CI 95.0% to 100.0%) and specificity of 72.1% (95% CI 70.0% to 74.1%) to predict cases with TBI.

A symptom-driven CT rule has been derived to identify cases at high risk of having TBI in fully conscious, but symptomatic children with mild closed head injury. To be practical, an additional observation rule is added.

This was a sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome in an urban teaching hospital. Adult patients with non-traumatic chest pain were eligible for inclusion. Those with ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. Low risk was defined as a TIMI risk score of 0 and initial TnI ≤99th centile. Primary outcome of interest was defined as MACE within 7 days. MACE included death, cardiac arrest, revascularisation, cardiogenic shock, arrhythmia, and prevalent (cause of presentation) and incident (occurring within the follow-up period) myocardial infarction (MI). Analysis was by descriptive and clinical performance analyses.

651 patients were studied of whom 215 met the low risk criteria. There was one MACE in this group (0.47%, 95% CI 0.08% to 2.6%)—a revascularisation within 7 days without prevalent MI. Negative predictive value of low risk classification was 99.5% (95% CI 97% to 100%) at both 7 and 30 days. Negative likelihood ratio, weighted by prevalence, was 0.005 at both intervals.

Risk stratification for early discharge based on ECG, TIMI score of 0 and presentation TnI ≤99th centile appears to identify a group at very low risk of MACE. Research to prospectively validate this is warranted.

In a retrospective study, the medical records of all DSP patients older than 16 years, who presented to the ED from 1 January 2009 to 31 December 2009, were reviewed.

312 episodes of DSP were included, accounting for 0.6% of all ED visits. 190 patients were women, with a female to male ratio of 1.56:1. Mean patient age was 37 years. More than 60% (n=190) of DSP patients were <40 years of age. Most patients presented to the ED between 18:00 and 23:00. A single drug was ingested in 39% (n=121) of patients. Alcohol was co-ingested by 36% of patients who were mostly middle-aged men. Of the overdoses, 50.8% were due to benzodiazepines, 23.2% were due to antidepressants and 16.4% were due to antipsychotics. Two-thirds of patients were treated with oral activated charcoal and 89% were seen by a psychiatrist. Nearly 90% of patients were admitted to the ED observation ward, with a mean length of stay of 16.7 h. The estimated total cost was ;266 134.89, with an average of ;872.57 per patient.

Self-poisoning cases in Belgium are grossly similar to those in other Western countries. Supportive treatment alone should be considered in the majority of patients presenting with oral drug overdose. Overall, DSP leads to a significant financial burden on the community.

To determine how well treating doctors assess risk factor status and whether a standardised proforma is useful in the risk stratification process.

Retrospective 12-month case note review of all patients presenting with paracetamol poisoning to our large inner-city emergency department. Data were collected on the documentation of risk factors, the presence of a local hospital proforma and treatment outcomes.

249 presentations were analysed and only 59 (23.7%) had full documentation of all the risk factors required to make a complete risk assessment. 56 of the 59 (94.9%) had the local hospital proforma included in the notes; the remaining 3 (5.1%) had full documentation of risk factors despite the absence of a proforma. A local hospital proforma was more likely to be included in the emergency department notes in those with ‘adequate documentation’ (78 out of 120 (65%)) than for those with ‘inadequate documentation’ (16 out of 129 (12.4%)); X², p<0.001.

Despite a low overall uptake of the proforma, use of a standardised proforma significantly increased the likelihood of documentation of the risk factors which increase risk for hepatotoxicity following paracetamol poisoning.

A large teaching hospital with an annual ED census of 120 000 adult patients.

A prospective, randomised placebo controlled trial of a convenience sample of patients attending the ED. The trial compared the analgesic effect of intravenous hyoscine butylbromide, oral paracetamol and the combination of both drugs using a Visual Analogue Scale pain scoring tool. Rescue analgesia was administered when pain was inadequately controlled by trial medication.

132 patients were recruited to the trial. At 30 min, all analgesic combinations produced significant similar levels of pain relief. At 60 min after administration of the trial medication, mean reductions in pain scores for patients receiving paracetamol only were significantly greater than those receiving paracetamol + hyoscine butylbromide (ANCOVA model, p=0.0180). No relationship was seen between treatment arm and the need for rescue analgesia (², p value=0.846).

The trial data suggest that oral paracetamol is at least as effective as intravenous hyoscine butylbromide and a combination of both drugs in the management of acute undifferentiated abdominal pain presenting to the ED. Based on these results and factors such as cost and tolerability, we recommend single agent paracetamol as the agent of choice for the management of acute mild to moderate undifferentiated abdominal pain.

MHRA Ref: 19717/0226/001-0001; European Clinical Trials Database. EUDRAct No: 2006-005395-40.

To determine the pattern of CRP determinations in the emergency department (ED) of a university hospital in Sao Paulo, Brazil, and to evaluate the effect of an intervention with staff and students about the best use of the test in the ED.

Data regarding CRP testing requests, related diagnoses and the number of monthly consultations in the hospital ED were analysed before and after the intervention. Because of an increase in CRP measurement requests from 2007 to 2009, the author started discussing the role of CRP determinations in the medical decision-making process in early 2010. Staff and faculty members openly discussed the pattern of requests in the hospital and related current medical literature. During 2010, the medical staff worked as multipliers to change the behaviour of new students and residents. The results of the first 4 months after the intervention were presented at another general meeting in July 2010.

From 2007 to 2009, there were 11 786 CRP measurement requests with a clear exponential trend. After the intervention, during the calendar year 2010, there was a 48% reduction in adjusted annual CRP requests. Pneumonia, fever and urinary tract infections were the most common reasons for CRP requests.

Inexpensive, well-directed, interactive educational interventions may affect professional behaviour and curb rates of laboratory tests.

74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13–15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded.

Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention.

Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.

Penetrating injuries by small, sharp objects (eg, knifes, projectiles) occur frequently in prehospital emergency medicine. Here,...]]> 2012-01-20T12:34:48-08:00 info:doi/10.1136/emermed-2011-200860 hwp:master-id:emermed;emermed-2011-200860 British Association for Accident and Emergency Medicine 2012-01-20 Images in emergency medicine http://emj.bmj.com/cgi/content/short/emermed-2011-200523v1?rss=1 Objective

To determine the frequency with which a CT head is performed in patients presenting more than 4 h after minor head injury and the clinical features that predict an abnormal scan.

Observational cohort study.

Emergency department (ED) of the Royal London Hospital, London, UK.

500 patients presenting to the ED of the Royal London Hospital.

Chart review of all patients with minor head injury presenting more than 4 h from insult to the ED between December 2007 and May 2009. Inclusion criteria were: age over 16 years, Glasgow coma scale (GCS) 14 or 15 on first assessment, over 4 h post-injury. Exclusion criteria were: age under 16 years, GCS 13 and less, injuries limited to the face with no risk of intracranial injury; presentation less than 4 h after injury.

497 patients were identified: 147 patients had CT head; 11 had intracranial injuries on CT. Loss of consciousness (p=0.0005), potential coagulopathy (p=0.0015), injuries above the clavicles (p=0.0150), open/depressed skull fracture (p=0.0221), alcohol/drug intoxication (p=0.0406) and focal neurology (p=0.0562) were predictors of positive CT scan. Five patients (1% of sample, 45% of patients with abnormal CT) required a neurosurgical procedure. Two (18.2%) self-discharged and four (36.4%) were followed up as outpatients. One patient (0.09%) died as a result of intracranial injury.

Patients with minor head injury who present over 4 h post-insult exhibit a similar risk of intracranial pathology to those presenting within 4 h. The risk factors previously identified to predict intracranial injury are similar in this study.

To examine the causes and effects of ED crowding, along with solutions. To consider whether the 4 h standard has had an effect on ED crowding in the UK.

A structured literature review on ED crowding.

The evidence base largely consists of retrospective or descriptive studies (65% combined) from North America and Australasia (89% combined). Measurement of crowding is not well developed, and the lack of a gold standard additionally limits the quality of research. The main cause of crowding is access block, because of high levels of hospital occupancy. Crowding carries a number of adverse consequences for patients and staff. Many solutions are described, but with weak evidence behind them. Most of these focus on interventions in the ED, despite the fact that the main causes lie outside. Solutions aimed at achieving the 4 h standard may mitigate crowding.

The extent of ED crowding in the UK is unknown. The problem is probably mitigated by process standards such as the 4 h standard. The causes and effects of crowding are likely to be the same as overseas, but there is little research to validate this. The best solutions are not known.

Literature review, semi-structured interviews and observations of handover were used to develop a standardised process for handover. Participants were ED middle grades, consultants and senior nurses. Interviews were used to identify agreed best practice and derive a tool to classify the information into relevant sections.

Interviews identified a variety of perceived current deficits in handover including a lack of standardised practice and structure. Participants provided examples of poor handover that were thought to have led to adverse events; these included delay in investigations and treatment for patients who were handed over with brief or inaccurate information. There was wide variation in the understanding of the meaning and purpose of shift handover, and differences were apparent according to the level of experience of the middle grades interviewed. The experts' responses were used to reach a unifying ‘best practice’ for the content of handover. This was then grouped under ABCDE headings to develop the ABC of handover tool.

A simple tool was developed to provide the basis for medical shift handover, which includes clinical and operational information necessary for efficiency and organisation of the next shift. The ABC of handover classifies shift information to be handed over under the ABCDE headings, which are easy to remember and highly relevant to emergency medicine.

Trauma patients aged 3–17 attending the ED were included in the study group. Parents were informed after medical care had been given to their children, and demographic data and information about the trauma were collected. Later, parents were asked to complete the Conners' Parent Rating Scales-Revised questionnaire for ADHD symptoms. The control group consisted of children of similar age and sociocultural characteristics who attended the hospital for reasons other than trauma. Cases in which the child apparently had no active role in the trauma or where the parents did not complete the Conners' Parent Rating Scales-Revised questionnaire were excluded from the study.

Fifty-five children were included in the study group (mean age 7.49 (range 3–14; SD 3.3); 33 (60%) were male). The control group was statistically similar to the study group. The most common trauma mechanism was falls (n=31, 56.4%). All the subscale scores were significantly higher in the study group, and previous trauma-related ED visits were associated with significantly higher subscale scores.

The data suggest that children who make repeated trauma-related ED visits have a predisposition to ADHD, and they may benefit from screening for this disorder while in the ED.

A prospective observational before and after study was performed to explore the effect of implementing ‘The ABC of Handover’ on clinical and organisational practice using a questionnaire.

41 handovers were observed before implementation of ‘The ABC of Handover’ and 42 were observed after. The new tool was successfully implemented and resulted in a change of practice which led to a significant increase in the operational issues mentioned at handover from a mean of 34% to a mean of 86% of essential items with the ABC method. Over the study period, middle-grade staff demonstrated improved situational awareness as they adopted proactive management of operational issues such as staffing or equipment shortages. All participants reported that ‘The ABC of Handover’ improved handover regardless of the seniority of the doctor giving it, and found the ABC method easy to learn.

Successful implementation of ‘The ABC of Handover’ led to a change of practice in the ED. Improving handover resulted in better organisation of the shift and heightened awareness of potential patient safety issues. The ABC method provides a framework for organising the shift and preparing for events in the subsequent shift.

Interview study.

One acute hospital (University Hospitals of Leicester) in the East Midlands.

23 patients and/or their carers.

A purposive sample of patients attending the ED and the linked urgent care centre was identified and recruited. Patients in the sample were approached by a clinician and a researcher and invited to take part in an interview. Patients of different ethnicities and from different age groups, arriving at the ED via different referral routes (self-referral, emergency ambulance, GP referral, out-of-hours services) and attending at different times of the day and night were included. The interviews were recorded and transcribed with the individuals' permission and analysed using the framework analysis approach.

Patients' anxiety or concern about the presenting problem, the range of services available to the ED and the perceived efficacy of these services, patients' perceptions of access to alternative services including general practice and lack of alternative pathways were factors that influenced the decision to use the ED.

Access to general practice, anxiety about the presenting problem, awareness and perceptions of the efficacy of the services available in the ED and lack of alternative pathways are important predictors of attendance rates.

A three round Delphi study was conducted via email and an Internet based survey tool. The panel consisted of 40 professionals who had exposure to and expertise in crowding. Participants submitted quantified crowding measures which, through three rounds, were evaluated and ranked to assess participant agreement for inclusion.

The panel identified 27 measures of which eight (29.6%) reached consensus at the end of the study. These measures comprised: (1) ability of ambulances to offload; (2) patients who leave without being seen or treated; (3) time until triage; (4) ED occupancy rate; (5) patients' total length of stay in the ED; (6) time to see a physician; (7) ED boarding time; and (8) number of patients boarding in the ED.

This study resulted in the identification of eight quantified crowding measures, which present a comprehensive view of how crowding is affecting ED operations, and highlighted areas of concern. These quantified measures have the potential to make a considerable contribution to decision making by ED management and to provide a basis for learning across different departments.

This was a qualitative study involving semistructured interviews. Data were collected from staff working in the ED of a London teaching hospital. A purposive sampling method was employed to recruit staff from a variety of grades and included both doctors and nurses.

22 staff members took part in the study. The most frequently mentioned stressors included the ‘4-hour’ target, excess workload, staff shortages and lack of teamwork, both within the ED and with inpatient staff. Leadership and teamwork were found to be mediating factors between objective stress (eg, workload and staffing) and the subjective experience. Participants described the impact of high pressure on communication practices, departmental overview and the management of staff and patients. The study also revealed high levels of misunderstanding between senior and junior staff. Suggested interventions related to leadership and teamwork training, advertising staff breaks, efforts to help staff remain calm under pressure and addressing team motivation.

This study highlights the variety of stressors that ED staff are subject to and considers a number of cost-efficient interventions. Medical education needs to expand to include training in leadership and other ‘non-technical’ skills in addition to traditional clinical skills.

A randomised double-blind study was performed to compare the efficacy of intravenous paracetamol (1 g) and 0.1 mg/kg morphine in patients with renal colic. The efficacy of the study drugs was measured by a visual analogue scale and a verbal rating scale at baseline and after 15 and 30 min. The adverse effects and need for rescue medication (1 μg/kg intravenous fentanyl) were also recorded at the end of the study.

133 patients were eligible for enrolment in the study, with 73 patients included in the final analysis (38 in the paracetamol group and 35 in the morphine group). The mean±SD age of the subjects was 30.2±8.6 years and 51 (70%) were men. The mean reduction in scores at 30 min after study drug administration was 63.7 mm (95% CI 57 to 71) for paracetamol and 56.6 mm (95% CI 48 to 65) for morphine. The difference between pain reduction scores for the two groups at 30 min was 7.1 mm (95% CI –18 to 4), demonstrating no statistical or clinical significance. Two adverse events (5.3%) were recorded in the paracetamol group and five (14.3%) in the morphine group (difference 9%, 95% CI –7% to 26%).

Intravenous paracetamol is effective in treating patients presenting with renal colic to the emergency department.

ClinicalTrials.gov ID number NCT01318187.

This was a retrospective study. Significant variables that affected 28-day mortality were analysed using multivariate logistic regression. Study patients were classified into three groups: no coagulopathy, mild coagulopathy or severe coagulopathy. Concordance between actual and predicted survival rates were compared for each group. The predicted survival rate was calculated using the TRISS method. The study also determined whether changes in the coagulation state during inhospital resuscitation affected the relationship between actual and predicted survival in patients who had rechecked coagulation profile within 12 h after presentation.

Data from a total of 336 patients were analysed. At presentation, 20.8% of the study patients had mild coagulopathy, whereas 7.7% had severe coagulopathy. Age, injury severity score, revised trauma score and presence of ATC at presentation were independently associated with 28-day mortality. Actual survival was significantly lower than predicted survival in the mild and severe coagulopathy groups. Aggravation of coagulation state from normal or mild to severe coagulopathy or persistent severe coagulopathy during inhospital resuscitation mainly contributed to the discrepancy between actual and predicted survival.

ATC decreased actual survival more than expected. ATC should be combined with TRISS to predict trauma outcome in severely injured patients. Improvement in coagulopathy during resuscitation may reduce the incidence of preventable death after trauma.

Analysis of current quantitative methods to assess emergency care in developing countries, and the proposal of a more appropriate method.

Currently accepted methods to quantitatively assess the efficacy of emergency care systems cannot be performed in most developing countries due to weak record-keeping infrastructure and the inappropriateness of applying Western derived coefficients to developing country conditions. As a result, although emergency care in the developing world is rapidly growing, researchers and clinicians are unable to objectively measure its progress or determine which policies work best in their respective countries. We propose the TEWS methodology, a simple analytical tool that can be handled by low-resource, developing countries.

By relying on the most basic universal parameters, simplest calculations and straightforward protocol, the TEWS methodology allows for widespread analysis of emergency care in the developing world. This could become essential in the establishment and growth of new emergency care systems worldwide.

To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department (ED), and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality.

Single-centre retrospective study of 176 consecutive patients with PE, assessed by MT in the ED between January 2006 and October 2010 (mean age 70.5±15.7 years, 38.6% men). The primary outcome measure was all-cause IHM.

IHM was seen in 30 (17%) patients. More than half of the patients with PE (54%) were classified as target time for first medical observation (MOb) ≤10 min. 73.3% of IHM occurred in this group (p=0.020) with several increased markers of illness severity. MOb ≤10 min was not associated with faster PE imaging confirmation. The average door-to-diagnosis time (PEDx) was 26.8±36.8 h and PEDx >17.0 h was associated with higher IHM (p=0.017). On multivariate analysis, thrombolysis and MOb ≤10 min were included in an IHM predictor model.

MT has high sensitivity in identifying patients with PE at risk. Those patients assigned as MOb ≤10 min have increased markers of illness severity and higher IHM. MT acts as a protective system in this challenging set and should be used as a patient's first assessment, aiding the emergency medical team to recognise those in need of urgent assessment and treatment.

The study consisted of 4500 mothers with children 0–12 years of age who were referred to the pediatric health and disease polyclinic and primary care polyclinic over a period of 24 months. Data were collected using a questionnaire containing 32 open-ended, multichoice questions, and assessed using number, percentage and ² analyses.

In this study, 36% of mothers regarded body temperatures lower than 37°C as fever; 83% believed that fever was harmful for their children, and 92.3% experienced fear and concern due to their child's fever. The most significant reason for fear was the belief that the child may have a seizure. Moreover, 12% of mothers feared that their child would die due to fever. The level of fear triggered by fever was lower as the education level of the mothers increased. Meanwhile, when their child had a fever, 28.9% of mothers used antifebrile drugs without consulting a physician, while 19% applied cold water and 7.7% applied water with alcohol or vinegar, among other inappropriate practices.

Increased information about fevers geared towards the caregivers of children, particularly mothers, would prevent the unnecessary treatment of children, as well as minimising delayed and insufficient responses to fever.

All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED.

In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks.

Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

To validate the AHFI prospectively.

Using a prospective cohort study, adult patients presenting to an urban university hospital ED with DHF were included. Data on 21 variables were gathered to calculate the AHFI. Primary endpoints included inpatient death and non-fatal serious outcomes (myocardial infarction, ventricular fibrillation, cardiogenic shock, cardiac arrest, intubation, or cardiac reperfusion). Secondary endpoints included death from any cause or readmission for heart failure within 30 days. Primary and secondary endpoint rates were calculated with 95% CI for the low and higher-risk subgroups.

259 patients were enrolled. 245/259 (95%) were admitted. 60/259 (23%) met low-risk criteria, of whom 1/60 (1.7%, CI 0.04 to 8.9) was discharged after sustaining pulseless electrical activity arrest. The comparable primary outcome rate in the derivation study was 1.4% (CI 1.1 to 1.7). 17/199 (8.5%, CI 5.1 to 13.3) higher-risk patients experienced an endpoint, compared with 13.3% (CI 12.9 to 13.7) in the derivation cohort. One low-risk patient (1.7%, CI 0.04 to 8.9) died within 30 days, and five (8.3%, CI 2.8 to 18.4) were readmitted. Corresponding rates in the derivation study were 2% and 5%, respectively.

The results are consistent with those previously reported for the low-risk subgroup of the AHFI. Further research is needed to determine the impact, safety and full range of generalisability of the AHFI as an adjunct to decision making.

A study was carried out on dexmedetomidine for sedation of patients with acute behavioural disturbance for whom at least two previous attempts at sedation with other drugs had failed. Either a loading dose of dexmedetomidine was administered or a loading dose then an infusion. Administration was titrated to the sedative effect and vital signs. The sedation assessment tool was used to assess effectiveness, and adverse effects were recorded. Effective sedation was defined as a fall in the sedation assessment tool by two levels or more for an hour or more.

A total of 13 patients were given dexmedetomidine. Five of the 13 had a loading dose only. Of these five, successful sedation was achieved in two, and the other three were only briefly sedated during the loading dose. One patient had hypotension. Eight patients received an infusion after the loading dose. Three were successfully sedated, but one developed hypotension. Four patients required a decrease in the infusion rate for hypotension, and in three of these the rate decrease compromised the sedation and one of these required intubation for sedation. The final patient had persistent acute behavioural disturbance, which required intubation for management. Five of the eight patients developed hypotension, and, of the five, one had bradycardia and one went into atrial fibrillation.

Intravenous dexmedetomidine for difficult-to-sedate patients with acute behavioural disturbance is not safe in the emergency department setting.

Eighty-three first-year healthcare students were enrolled in a prospective randomised crossover study comparing chest compression quality during uninterrupted chest compression CPR after approach from both their preferred and non-preferred sides.

Chest compression quality was not dependent on rescuers' sidedness preference; neither mean compression rate and depth nor hand positioning differed between sides of approach.

No link exists between the side from which a rescuer approaches, or prefers to approach, a casualty and chest compression quality.

In an open label randomised study, 18 subjects with stable severe COPD attended on 2 days to receive nebulised bronchodilator therapy driven by air or oxygen. Subjects received 5 mg salbutamol and 0.5 mg ipratropium bromide by nebulisation over 15 min, then, after 5 min, 5 mg salbutamol nebulised over 15 min, followed by 15 min of observation. Transcutaneous carbon dioxide tension (Ptco₂) and oxygen saturations were recorded at 5 min intervals during the study. The primary outcome was the Ptco₂ after the completion of the second bronchodilator treatment.

Ptco₂ was higher with nebulised bronchodilator therapy delivered by oxygen, but decreased back to the level associated with air nebulisation 15 min after completion of the second nebulised dose. One subject experienced an increase in Ptco₂ of 11 mm Hg after the first bronchodilator nebulisation driven by oxygen. The mean Ptco₂ difference between the oxygen and air groups after the second nebulisation was 3.1 mm Hg (95% CI 1.6 to 4.5, p<0.001).

Nebulisers driven with oxygen result in significantly higher levels of Ptco₂ than those driven with air in patients with severe COPD.

The study was registered on the Australian New Zealand Clinical Trials Registry (ACTRN12610000080022).

The computerised CT request notes were reviewed on all patients who underwent a CT head scan with a minor head injury over a 1-year period (January 2009–December 2009). The clinical signs and symptoms at presentation were extracted from the request notes and the RR ratios were calculated for five clinical correlates: LOC, PTA, vomiting, nausea and headache.

456 Glasgow coma scale (GCS) 15 patients underwent CT scanning during the period January 2009–December 2009. 55 of the 456 patients had positive CT findings (12%). 270 patients (59%) of the GCS 15 cohort had neither LOC nor PTA and of this subgroup 27 had positive scans. LOC was the only clinical correlate in which the RR reached statistical significance; RR 2.0930 (95% CI 1.25 to 3.50). However, vomiting accounted for four cases, headache for four cases and nausea for no cases.

Using LOC or PTA as the principal entry criterion for CT scanning may result in a significant number of patients with traumatic intracranial injury being missed. Using a less stringent approach still achieved an acceptable CT abnormality rate.

This 2-year prospective observational investigation involved the collection of tape recordings of all incoming calls to the emergency medical dispatch centre, in which an out-of-hospital non-traumatic seizure was the chief complaint in patients >18 years, in addition to the paramedics' records of all patients who presented with respiratory or cardiac arrest. The authors also recorded whether the bystander spontaneously mentioned to the dispatcher that the victim was known to have epilepsy.

During the 24-month period, the call centre received 561 incoming calls for an out-of-hospital non-traumatic seizure in an adult. Twelve cases were classified as cardiac or respiratory arrest by paramedics. In one case, the caller spontaneously mentioned that the victim had a history of epilepsy. The proportion of cardiac or respiratory arrest among calls for seizure was 2.1%.

Although these cases are rare, dispatchers should closely monitor seizure patients with the help of bystanders to exclude an out-of-hospital cardiac or respiratory arrest, in which case the dispatcher can offer telephone cardiopulmonary resuscitation advice until the paramedics arrive. Whenever the activity of the centre allows it and no new incoming call is on hold, this can be achieved by staying on the line with the caller or by calling back. A history of epilepsy should not modify the type of monitoring performed by the dispatcher as those patients may also have an arrest together with seizure.

A self-observational audit study of interruptions was undertaken by a consultant emergency physician in a medium-sized ED over 25 separate shifts totalling 119 h. The main outcome measures were type and occurrence of interruption in relation to mode of original task. ‘Success’ of interruptions and number of outstanding tasks were also recorded.

718 interruptions were recorded, with an average of 6 per hour. A mean number of 2.44 outstanding tasks were recorded on each occasion of interruption. Verbal advice, telephone calls and interpretations of x-rays were the most common forms of interruption. 498 interruptions (69%) were successful, defined as interruptions that resulted in a task break (over-riding and suspension of the original task). The most successful interruptions were calls to the resuscitation room (95%). Interruptions from electronic telecommunications systems were extensive (33% of total) with success dependent on the type of communication system. Telephone conversations were rarely interrupted (16% compared with a mean of 69%).

Overt electronic communication systems may have a disproportionate impact in determining the likelihood for successful interruptions. Formal consideration of how to prioritise and manage interruptions from various channels could be usefully added to emergency medicine education and training.

Patients who presented to the emergency department within 4 h of the onset of chest pain suggestive of acute coronary syndrome were prospectively recruited from November 2007 to April 2010. Blood samples were taken at 0, 1, 2 and 12–24 h after presentation and were analysed for clinically applied troponin I and for high-sensitivity troponin T (hsTnT). The dynamic change in hsTnT levels between time points was measured. The primary outcome was admission diagnosis of AMI.

Of the 385 patients recruited, 82 (21.3%) had AMI. The sensitivity of hsTnT by 2 h was 95.1% (88.7–98.1%), specificity 75.6% (73.8–76.5%), positive predictive value 53.8% (50.2–55.5%) and negative predictive value 98.3% (96.0–99.3%). The sensitivity was not statistically different between peak values at 2 h and 24 h. Adding ECG results reduced the false negative rate to 1.2%. The additional application of ≥20% delta criterion over the 2 h period for 0–2 h samples increased specificity to 92.4% (90.2–94.3%) but reduced sensitivity to 56.1% (48.0–63.2%).

hsTnT taken at 0 and 2 h after presentation, together with ECG results, could identify patients suitable for early stress testing with a false negative rate for AMI of 1.2%. Further trials of such an approach are warranted. The specificity of hsTnT for diagnosing AMI could be improved by the use of a delta of ≥20%, but at the cost of major reductions in sensitivity.

An observational time-and-motion study was carried out at three emergency departments. A single investigator followed emergency doctors and recorded the time spent on various work activities. Job activities were classified into 12 different main categories, including direct or indirect patient care.

The data showed that doctors in emergency departments had to work overtime (M=09.17 h). They performed more than 80 tasks per day and were forced to handle multitasking situations. Indirect patient care and administrative duties were the main tasks doctors spent time on during the day. Direct patient care and contact represented only a small proportion of work time.

Doctors working in emergency care units have to deal with highly unpredictable workloads and overtime work, and simultaneously should also care for patients and interact with a large number of different persons during each work shift. The findings of this study are useful in efforts to improve emergency medical care and doctors' working conditions.

A literature review was undertaken using the electronic medical databases Ovid Medline, EMBASE, CINHAL Plus, Cochrane Systematic Review and Meditext, from their commencement to the end of June 2011. Keywords used in the search included: CPR, defibrillation, ventricular fibrillation, VF, EMS, EMT, paramedic, emergency medical service, emergency medical technician, prehospital, out-of-hospital and ambulance. References of relevant articles were also reviewed.

Of the 3079 articles located, 10 met the inclusion criteria. The results of these studies showed conflicting results. All retrospective studies (n=6) indicated a benefit in performing pre-shock CPR on patients with ventricular fibrillation for durations between 90 and 180 s. Conversely, all randomised controlled trials demonstrated no benefit from providing CPR before defibrillation compared with immediate defibrillation for return of spontaneous circulation, neurological outcome and/or survival to hospital discharge. However, none of the studies reported evidence that CPR before defibrillation is harmful.

Conflicting evidence remains regarding the benefit of CPR before defibrillation. The establishment of a consistent timeframe of chest compressions before defibrillation in the out-of-hospital setting will provide uniformity in standards in clinical practice and education and training.

To determine whether emergency physicians perceived their clinical decisions in general to be more experiential or rational and how this compared with other physicians.

A validated psychometric tool, the Rational Experiential Inventory (REI-40), was sent through postal mail to all emergency physicians registered with the College of Physicians and Surgeons of Ontario, according to their website in November 2009. Forty statements were ranked on a Likert scale from 1 (Definitely False) to 5 (Definitely True). An initial survey was sent out, followed by reminder cards and a second survey to non-respondents. Analysis included descriptive statistics, Student t tests, analysis of variance and comparison of mean scores with those of cardiologists from New Zealand.

The response rate in this study was 46.9% (434/925). The respondents' median age was 41–50 years; they were mostly men (72.6%) and most had more than 10 years of clinical experience (66.8%). The mean REI-40 rational scores were higher than the experiential scores (3.93/5 (SD 0.35) vs 3.33/5 (SD 0.49), p<0.0001), similar to the mean scores of cardiologists from New Zealand (mean rational 3.93/5, mean experiential 3.05/5). The mean experiential scores were significantly higher for female respondents than for male respondents (3.40/5 (SD 0.49) vs 3.30/5 (SD 0.48), p=0.003).

Overall, emergency physicians favoured rational decision making rather than experiential decision making; however, female emergency physicians had higher experiential scores than male emergency physicians. This has important implications for future knowledge translation and decision support efforts among emergency physicians.

The outcomes of all stroke patients thrombolysed at Scarborough DGH from 2004 to January 2009 were reviewed. Outcome was defined using a three-part scale. Data at Scarborough DGH were compared with data from the SITS-MOST European-wide study of stroke thrombolysis.

Data were available for 98 of 110 patients thrombolysed during the study period. Fifty (51%) had a good outcome, seven (8%) had partial resolution of their symptoms, and 41 (42%) showed no improvement or deterioration. These outcomes were comparable to those in the European database.

Stroke thrombolysis can be effectively delivered in a non-specialist (a non-hyper-acute stroke centre) DGH in the UK. An audit of cases completed describes complications seen.

All ED open 24 h/day 7 days/week to the general public were surveyed using the national ED inventories survey instrument (http://www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to calendar year 2008.

Twenty-four ED participated (83% response). All were located in hospitals, which ranged in size from six to 250 beds. The majority (92% CI 73% to 100%) had a contiguous layout with medical and surgical care provided in one area. All ED saw both adults and children, with a median of 1500 annual visits (IQR 648–2328). Almost half of respondents (46%; CI 26% to 67%) thought their ED operated under capacity, none thought that their ED was over capacity. Only 4% of ED surveyed had dedicated CT scanners, 25% had cardiac monitoring and none had negative-pressure rooms. There was wide variation in the types of emergencies that were identified as being treatable 24 h/day 7 days/week; these appeared to correlate with ED consultant availability.

Although ED location and layout in Abuja do not differ greatly from that in a typical US city, ED utilisation was lower and fewer resources and capabilities were available. The lack of technological and human resources raise questions about what critical technologies are needed in resource-limited settings, and whether Nigeria should consider training emergency medicine physicians to meet its workforce needs.

The two main objectives of this study were (1) to determine the perceived preparedness of acute care providers in New Zealand to respond to the healthcare demands of RWC 2011; and (2) to determine the factors associated with perceived strong preparedness among acute care providers in New Zealand.

A cross-sectional survey of 1500 doctors, nurses and ambulance officers working in acute care services in New Zealand was conducted between June 2010 and March 2011.

911 surveys were completed (response rate 60.7%). Only 12.7% of acute care providers felt they were prepared to deal with possible health issues arising from RWC 2011. Perceived preparedness was highest among ambulance officers and lowest among providers in intensive care units (16.3% vs 4.1%, p<0.01). Acute care providers who were aware of their role in a mass emergency were more likely to report preparedness with a prevalence OR of 3.5 and a 95% CI of 2.1 to 5.7.

Only 12.7% of acute care providers in New Zealand perceived preparedness for RWC 2011. Perceived preparedness followed a stepwise decline from prehospital services, emergency department, to surgery and then finally to intensive care services. This indicates that current preparedness activities are focusing on prehospital emergency services and neglecting surgical and intensive care services. Awareness about the role of acute care providers during emergencies, training and previous experience were associated with perceived strong preparedness for RWC 2011.

The aim of this study was to evaluate the accuracy of these devices to guide chest compressions on a dental chair.

A prospective, randomised, crossover, equivalence/non-inferiority study was conducted to compare the values of compression depths provided by the feedback device (Real CPR Help^®, delivered by Zoll© Medical Corporation, Chelmsford, MA, USA) with the real measurements provided by the manikin (Resusci Anne^® Advanced SkillTrainer, Laerdal Medical AS©, Norway). Chest-compression-only CPR was performed by 15 Basic Life Support instructors who carried out two rounds of continuous CPR for 2 min each. Data were analysed with a correlation test, a Bland–Altman method and a Wilcoxon test. Statistical significance was defined as p<0.05.

A significant difference was found between the mean depths of compression measured by the feedback device and the manikin on a dental chair and on the floor (p<0.0001). The feedback device overestimated the depth of chest compressions, and Bland–Altman analysis demonstrated poor agreement.

This study indicates that feedback devices with accelerometer technology are not sufficiently reliable to ensure adequate chest compression on dental chairs.

The baseline performance of BLS skills in medical doctors during their internship was tested immediately after the BLS provider course. The subjects were divided into two groups, which were tested using the same method after 6 months or after 12 months. Data on the subjects' CPR experience were collected through CPR records—specifically, the number of CPR experiences and the feedback given by the CPR team leaders. To evaluate BLS skill retention, baseline BLS skill performance was compared with the skill performances measured after 6 or 12 months.

Fifty-six subjects were enrolled in the 6 month group and 36 in the 12 month group. For non-compression skills, the points for skills declined from 12 to 6 points in the 6 month group and from 12 to 6 points in the 12 month group and the declines in both groups were statistically significant. For compression skills, in the 12 month group, the hands-off time improved from 9.9 s to 8.7 s, with statistical significance. In the multivariate linear regression test, the number of times feedback was given had a statistical relationship with improvement in hands-off time in the 12 month group (coefficient 0.58, 95% CI 0.12 to 1.05).

In medical doctors, the compression skills were well preserved, but the retention of non-compression skills was poor.

Two rounds of national organisational audit in 2005 and 2008 and one national clinical audit in 2006 were carried out based on indicators developed by a multidisciplinary group.

These showed that management of falls and bone health in older people remains suboptimal in emergency departments and minor injury units and opportunities are being missed in carrying out evidence-based risk assessment and management.

Older people attending emergency departments in the UK following a fall are receiving a poor deal. There is an urgent need to ensure more effective assessment and management to prevent further falls and fractures.

The study was based on an analysis of data prospectively collected from the MECU database in Copenhagen, Denmark. All unconscious (GCS scores below 9) non-trauma patients registered in the database during 2006 were included. The ambulance patient charts and medical records were scrutinised to assess outcome and the need for tracheal intubation during the first 24 h after admittance into hospital.

A total of 557 unconscious non-trauma patients were examined and 129 patients (23%) were tracheally intubated by the MECU physician before or during transport to the hospital. Intubation was done in most patients with cardiac arrest, severe stroke or respiratory failure. Of the remaining 428 patients, 364 (85%) regained consciousness before being transported to the hospital, whereas 64 patients remained unconscious during transport and 12 (19%) of these were intubated in the emergency department.

The majority of unconscious non-trauma patients were not intubated in the prehospital setting. Unconscious non-trauma patients may not all need tracheal intubation before being transferred to hospital.

A cross-sectional survey of attitudes of staff towards family presence in the resuscitation room was undertaken. All full-time doctors and nurses practising in emergency departments in the public sector in Trinidad and Tobago were surveyed, and the responses of doctors and nurses were compared.

214 individuals responded to the questionnaire (108 nurses and 106 doctors). 81.4% of respondents felt that relatives would be traumatised by witnessing resuscitation. 64% felt that staff performance would be inhibited by the presence of a family member during resuscitation. 71.1% believed that allowing a family member to witness resuscitation would prolong the resuscitation. 72% believed that witnessed resuscitation would increase the stress for the staff.

Strong feelings against the presence of family members in the resuscitation room were expressed by physicians and nurses. Implementation of such a policy will require careful preparation and education of staff as to the benefits of this intervention.

A descriptive retrospective study covering 5 years (2005–9) of historical data from 27 hospital EDs was undertaken. State-wide hospital ED Information System data were analysed. Annual comparisons between influenza and non-influenza cases were made across the southern hemisphere influenza season (June–September) each year.

Influenza-related presentations increased significantly over the 5 years from 3.4% in 2005 to 9.4% in 2009, reflecting a 276% relative increase. Differences over time regarding characteristics of patients with influenza-like symptoms, based on the influenza season, occurred for admission rate (decreased over time from 28% in 2005 to 18% in 2009), length of stay (decreased over time from a median of 210 min in 2005 to 164 min in 2009) and access block (increased over time from 33% to 41%). Also, every year there was a significantly (p<0.001) higher percentage of access block in the influenza cohort than in the non-influenza cohort.

Although there was a large increase over time in influenza-related ED presentations, most patients were discharged home from the ED. Special consideration of health service delivery management (eg, establishing an ‘influenza clinic border protection and public rollout of vaccination, beginning with those most at risk’) for this group of patients is warranted but requires evaluation. These results may inform planning for service delivery models during the influenza season.

Retrospective case series.

Three EDs within a single stroke service in northern England.

Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010.

Combined death and dependency at 90 days (0–2 on the modified Rankin Scale for a good outcome vs 3–6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage.

192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone).

In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

To quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa's first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa.

All 30 graduates from the first four classes in the UCT/SUN EM programme (2007–10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics.

Twenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations.

EM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

A needs assessment was undertaken in Manenberg, a township in Cape Town with high violence and injury rates. Community leaders and successfully established local services were consulted for the design of a first responder care delivery model. The resultant community-based emergency first aid responder (EFAR) system was implemented, and EFARs were tracked over time to determine skill retention and usage.

The EFAR system model and training curriculum. Basic EFARs are spread throughout the community with the option of becoming stationed advanced EFARs. All EFARs are overseen by a local organisation and a professional body, and are integrated with the local ambulance response if one exists. On competency examinations, all EFARs tested averaged 28.2% before training, 77.8% after training, 71.3% 4 months after training and 71.0% 6 months after training. EFARs reported using virtually every skill taught them, and further review showed that they had done so adequately.

The EFAR system is a low-cost, versatile model that can be used in a developing region both to lay the foundation for an emergency care system or support a new one to maturity.

An online survey distributed to members of the Australasian College for Emergency Medicine elicited decisions on commencing full treatment (CFT), limiting treatment or palliation in hypothetical clinical scenarios. Quantitative data were summarised using number and percentage.

388 surveys yielded a 13.0% response rate, including 190 fellows (51.9%) and 176 trainees (48.1%). For a 75-year-old patient with major trauma and unknown comorbidities requiring laparotomy, most participants (355/365, 97.3%) chose CFT. When an AD limiting treatment was made available, CFT decreased substantially (63/364, 17.3%), and the modal response was palliation (175/364, 48.1%). The most frequently reported influential factor in this decision was ethical obligation (82/383, 21.4%). For an elderly nursing-home resident with dementia, metastatic cancer and possible septic shock, 10.7% (39/366) chose CFT, changing little (21/365, 5.8%) with a directive requesting full treatment. The patient's presentation and history (189/375, 50.4%) overrode legal obligations (14/375, 3.7%) in influencing the decision. For a 55-year-old man with prostate cancer, hypoxia and acute respiratory distress (potentially requiring ventilatory support) saying, ‘I just want to end it all,’ most (233/366, 63.7%) chose CFT. A directive requesting limitation resulted in fewer decisions on CFT (43/368, 11.7%). Clear documentation was most important (100/362, 27.6%) in influencing this decision.

Hypothetical treatment decisions involving ADs made by emergency clinicians appear to be more influenced by ethical and clinical factors than by legal obligations.

FN episodes managed in an emergency department from June 2009 to May 2010 were included. Clinical and laboratory features including procalcitonin (PCT) and C reactive protein (CRP) were retrospectively analysed.

Of the total 285 episodes, 243 (85.3%) were classified as low risk. In this group, 19 (7.8%) had bacteraemia. There was a significant difference (p<0.05) in age, respiration rate ≥24 (36.8% vs 7.6%), Eastern Cooperative Oncology Group performance status (PS) ≥2 (42.1% vs 11.6%), platelet counts (107.0±42.4 vs 131.8±73.7 x10³/mm³), serum aspartate aminotransferase (42.3±30.7 vs 28.7±17.4 IU/litre) and blood urea nitrogen (19.6±9.8 vs 11.6± 8.6 mg/dl) between episodes with and without bacteraemia. PCT ≥0.5 ng/ml and CRP ≥10 mg/dl had higher rates of bacteraemia than PCT <0.5 ng/ml (28.2% vs 3.9%, p<0.001) and CRP <10 mg/dl (13.9% vs 5.3%, p=0.022) did. On multivariate analysis, PCT ≥0.5 ng/ml (OR 4.7, 95% CI 1.38 to 16.29), respiration rate ≥24 (OR 4.1, 95% CI 1.20 to 13.63) and Eastern Cooperative Oncology Group PS ≥2 (OR 3.2, 95% CI 1.02 to 10.10) were predictive of bacteraemia in the low-risk group.

PCT, tachypnoea and PS were predictive of bacteraemia in the low-risk patients with FN. If the patient has high probability of bacteraemia, the patient could benefit from parenteral antibiotic treatment while awaiting the blood culture results.

A total of 126 patients treated for seismic-related injuries at hospitals in the Chengdu area were investigated. Of the 126 patients, 46 (36.5%) had maxillofacial injuries. Gender, age, nationality and injury condition were recorded by talking with the patients and their families. The data were analysed using Microsoft Access 2003 and SPSS software programs.

For the 46 patients, the female to male ratio was 1.3:1 and the mean age was 36.7 years. Most patients (41, 89.1%) were Tibetan. The most frequent cause of maxillofacial injury was pressing/burying (34 patients, 73.9%). All patients with maxillofacial injuries sustained soft-tissue injuries, 13.0% had facial fractures and 4.3% had dentoalveolar injuries. The soft-tissue injuries were largely combined injuries; 84.8% were bruises and 80.4% were lacerations. The most common injury site was the zygomatic region (54.3%), followed by the forehead (43.5%) and the orbital region (34.8%). Of the six facial fractures, four involved nasal–orbital–ethmoidal region fractures. Most of the maxillofacial injuries (78.3%) were associated with other injuries, of which extremity injuries (55.6%) were the most common.

An analysis of the maxillofacial injuries sustained during the Yushu earthquake revealed some of the features of seismic-related maxillofacial injuries. The results from this study may help physicians provide better medical services during future disasters.

All fallers aged ≥70 years, presenting to the ED of a 450-bed metropolitan university hospital in Sydney, Australia (1 April 2007 through 31 March 2009) were studied. Data were collected from the ED electronic information system, ED clinical records and the hospital electronic information system database. Population estimates for 2008 for the local areas served by the hospital were used to estimate ED presentation rates.

Of 18 902 all-cause ED presentations, 3220 (17.0%) were due to a fall. Among fallers, 35.4% had one or more ED presentations and 20.3% had had one or more hospital admissions in the preceding 12 months. Fall-related ED presentation led directly to hospital admission in 42.7% of the cases, the majority of which (78.0%) received acute care only (length of stay—14.4 days for men and 13.7 days for women) and the remaining cases underwent further inpatient rehabilitation (length of stay 35.6 days for men and 30.1 days for women). After hospitalisation, 9.5% of patients became first-time residents of long-term care facilities. All fall-related ED presentations and hospitalisations cost a total of A$11 241 387 over the study period.

Older fallers presenting to the ED consume significant healthcare resources and are an easily identifiable high-risk population. They may benefit from systematic fall-risk assessment and tailored fall-prevention interventions.

The authors conducted a post-hoc analysis on a cohort of 2420 patients who died in 174 French and Belgian EDs. The authors identified patients who benefited from palliative care and described this population and the palliative care.

Palliative therapies were administered to 1373 patients (56.7%). These therapies included administration of analgesics, sedation, mouth care, repositioning for comfort (as appropriate) and provision of emotional support to the patient and his/her relatives. These palliative measures were provided more frequently in the observation unit of the ED (n=908, 66.2%) than in an examination room (n=465, 33.8%). Median time interval between ED admission and death was longer in patients who received palliative care (n=1373) (median, 15 h; first quartile, 6 h; third quartile, 34 h) than in those who did not (n=1047) (median, 4 h; first quartile, 1 h; third quartile, 10 h) (p<10^–4).

Palliative care is administered to about half of the patients who die in EDs. This is insufficient as the majority of the patients who died in EDs actually died after a decision to withhold or withdraw life-support therapies. End-of-life management must be improved in EDs.

Eight MR volunteers (age ± SD: 45.5 ± 8.9 years) completed a laboratory-based treadmill exercise test to exhaustion. One week later subjects completed a field-based simulated callout to retrieve a casualty by stretcher. In both studies exercise intensity was evaluated by determination of oxygen uptake and other cardiovascular measures.

The maximal oxygen uptake of the participants was 53 ml/kg/min (95% CI 45 to 60). In an unassisted callout, a typical rucksack load was 17% of body mass. Ascent time was 56 min (95% CI 40 to 72), of which 82% (95% CI 66% to 98%) was completed at hard or very hard intensity (above the respiratory compensation point). Descent time with a stretcher was 58 min (95% CI 52 to 64), of which only 6% (95% CI –4% to 16%) was completed at hard or very hard intensity. Correlations between heart rate and oxygen uptake were similar (p=0.254 by analysis of variance) during laboratory (r=0.72) and field testing, especially for the ascent (r=0.75).

Mountain rescuers generally have high levels of physical fitness and are required to perform at very hard intensity for the majority of the ascent to a casualty. Heart rate is a simple yet valid measure of exercise intensity in MR personnel. These findings highlight important information on the unique physical demands faced by MR volunteers and provide direction for future research, volunteer selection and training.

Participants were 148 boys and 144 girls. Before intervention, safety knowledge was assessed in a pencil and paper test. 198 children were taught the recovery position at a safety education centre. Three months later, their attempts to leave a casualty in a safe position were observed, and compared with the attempts of 94 children who had not received training.

19% of the control group and 31% of trained children successfully placed a casualty in the recovery position. Only two of the seven standard routine moves were used by more than 50% of trained children, namely raise the casualty's leg to a flexed position, roll the casualty on to his/her side. Even when performed, these and other individual moves were often not integrated into an effective routine.

The implication is that in a short session it is over-ambitious to attempt to teach a complex routine. It is more realistic to focus on a few moves which are easily learnt. The present results suggest that these should be flexing the leg and rolling the casualty on to his/her side. In this study, simply improving the participants' performance of these two moves could increase the number of learners who are successful from less than a third to nearly 50%.

Using electronic medical records of the National University Hospital in Reykjavík, a population-based register study was conducted contrasting weekly attendance rates at Reykjavík ED (cardiac and general ED) during 10-week periods in 2006, 2007 and 2008. The weekly number of all ED visits (major track), with discharge diagnoses, per total population at risk were used to estimate RR and 95% CI of ED attendance in weeks 41–46 (after the 2008 economic collapse) with the weekly average number of visits during weeks 37–40 (before the collapse) as reference.

Compared with the preceding weeks (37–40), the economic collapse in week 41 2008 was associated with a distinct increase in the total number of visits to the cardiac ED (RR 1.26; 95% CI 1.07 to 1.49), particularly among women (RR 1.41; 95% CI 1.17 to 1.69) and marginally among men (RR 1.15; 95% CI 0.96 to 1.37). A similar increase was not observed in week 41 at the general ED in 2008 or in either ED in 2007 or 2006. In week 41 2008, visits with ischaemic heart disease as discharge diagnoses (ICD-10: I20–25) were increased among women (RR 1.79; 95% CI 1.01 to 3.17) but not among men (RR 1.07; 95% CI 0.71 to 1.62).

The dramatic economic collapse in Iceland in October 2008 was associated with an immediate short-term increase in female attendance at the cardiac ED.

A prospective cohort study conducted in the ED of a university hospital. Patients were included if they had a clinical diagnosis of severe sepsis or septic shock. Thenar muscle tissue StO₂ on arrival in the ED and its change with usual ED sepsis management was measured using near-infrared spectroscopy. A follow-up measurement was obtained after 24 h of treatment. All patients were followed for 30 days.

49 patients were included, of which 24 (49%) died. There was no difference in mean StO₂ on arrival in the ED between survivors and non-survivors (72% vs 72%; p=0.97). Following ED treatment the mean StO₂ of survivors improved significantly to 78% (p<0.05) while StO₂ remained persistently low in non-survivors (p=0.94). Persistently low StO₂ (<75%) despite initial resuscitative treatment was associated with a twofold increase in mortality (RR of death 2.1%; 95% CI 1.2% to 3.5%).

Patients with severe sepsis/septic shock have abnormal muscle tissue StO₂ upon arrival in the ED. Inability to normalise StO₂ with ED sepsis management is associated with a poor outcome. The role of StO₂ as an early prognostic and potential therapeutic biomarker in severe sepsis or septic shock warrants further exploration.

To describe the use of advice or healthcare information among patients with non-urgent illnesses seeking care before attendance at an ED, or primary care (PC) centres in an urban region in Sweden.

Patients with non-urgent illnesses seeking care at an ED or patients attending the PC were followed up with a combination of patient interviews, a questionnaire to the treating physician and a prospective follow-up of healthcare use through a population-based registry.

Half of the non-urgent patients attending the ED had used healthcare information or advice before the visit, mainly from a healthcare professional source. In PC, men were more likely to have used information or advice compared with women (OR 2.5 95% CI 1.3 to 5.0), whereas the situation was reversed among ED patients (OR=0.4 95% CI 0.2 to 0.9). Men with no previous healthcare experience attending the ED had the lowest use of healthcare information (p<0.01). Very few in both groups had utilised healthcare information on the internet in a case of perceived emergency.

ED patients rated as non-urgent by the triage nurse used more advice and healthcare information than PC patients, irrespective of the physician-rated urgency of the symptoms. The problem seems not to be lack of information about appropriate ED use, but to find ways to direct the information to the right target group.

Retrospective review of medical records identified via the ED electronic database using ICD-10 codes for arrhythmias including cardiac arrests over a 6-year period (2002–2008). Patients <18 years were analysed using predefined criteria.

There were a total of 444 non-arrest arrhythmias with an incidence of 11.5:10 000 presentations. Median age of patients at presentation was 10.4 years; 45% were male. Supraventricular arrhythmias (SVTs) represented the largest subgroup (n=250, 56%). Conduction disorders (n=18), ventricular tachycardia (n=17) and atrial flutter/fibrillation (n=7) were rare. There were 19 cardiac arrests. Fifty-seven (13%) patients had underlying congenital heart disease. For ongoing SVT (n=135), vagal manoeuvres were used in 74%, and antiarrhythmic drugs in 64%. In five patients with SVT, drugs other than adenosine were used. Defibrillators were used only on 2 occasions for arrthymias and 6 times for cardiac arrests. 18 of 19 children in cardiac arrest died.

In this largest paediatric series outside the intensive care and postoperative setting, arrhythmias were uncommon, defibrillator use was very rare, and observed mortality was low.

To create an easily made, inexpensive, homemade phantom capable of simulating an abscess in superficial soft tissue infection.

Increasing amounts of Jell-O (Northfield, Illinois, USA) brand gelatin and sugar-free Metamucil (Cincinnati, Ohio, USA) brand psyllium hydrophilic mucilloid fibre were experimented with until a satisfactory model was achieved. Various liquids were injected into it to simulate superficial abscess formation. The desired goal was for the phantom to appear similar to superficial human soft tissue under ultrasound scan and to be firm enough to withstand pressure from an ultrasound probe scan. The goal for the simulated abscess was to appear as a hypoechoic space under ultrasound scan. A Sonosite M-Turbo (Bothell, Washington, USA) bedside ultrasound machine with linear array transducer probe was used for the ultrasound scans.

The optimal homemade phantom incorporated 12 tablespoons of Jell-O and four tablespoons of Metamucil in one liter of water.

An easily made, inexpensive phantom model for instruction on identification of superficial skin abscess was achieved.

To describe the outcomes in unconscious patients after near-hanging in order to determine whether TH improves the outcome of near-hanging injury.

Medical charts were reviewed of unconscious patients after near-hanging who presented to Chonnam National University Hospital between January 2006 and December 2010 and who were considered to be eligible for TH. According to local policy, unconscious survivors after near-hanging, whether or not they experienced cardiac arrest at the scene, were treated with TH if this was agreed by next-of-kin.

There were 16 survivors of asphyxial cardiac arrest after near-hanging, of whom 13 received TH. Among them, only one (7.7%, 95% CI 1.4% to 33.3%) attained Cerebral Performance Category (CPC) 1; the other 15 patients had poor neurological outcomes (CPC 5 in seven patients and CPC 4 in eight patients). Nine of the patients did not experience cardiac arrest at the scene and of these, four received TH and five received normothermic treatment. All patients who did not have cardiac arrest recovered and were discharged with CPC 1.

In this study, outcomes in unconscious near-hanging patients with cardiac arrest were poor despite treatment with TH. Before recommending TH in near-hanging patients, a prospective, randomised controlled study is required.

Questionnaire survey of a convenience sample of 204 physicians working in the departments of internal medicine, anaesthesiology and cardiology in 11 hospitals in Israel.

Twenty per cent of the participants had elected to forego resuscitating a patient they did not previously know without additional consultation. Physicians who had more frequently elected to forego resuscitation had practised medicine for more than 5 years (p=0.013), estimated the number of resuscitations they had performed as being higher (p=0.009), and perceived their experience in resuscitation as sufficient (p=0.001). The variable that predicted the outcome of always performing resuscitation in the logistic regression model was less than 5 years of experience in medicine (OR 0.227, 95% CI 0.065 to 0.793; p=0.02).

Physicians' level of experience may affect the probability of a patient's receiving resuscitation, whereas the physicians' personal beliefs and values did not seem to affect this outcome.

We conducted an anonymous survey of 300 non-cardiology medical registrars regarding their individual ability, experience and training received in temporary pacing wire (TPW) insertion.

A total of 202 (67%) responses were received. 61% (123) had not performed any TPW insertion before becoming a registrar. Only18% (38) felt confident in inserting a TPW unsupervised and only14 (7%) had ever received any formal training. The majority, 169 (84%), did not feel that their on-call consultant general physician would be able to perform the procedure.

This survey shows that general medical registrars lack a major life-saving skill that is required as part of CMT. Thus, there is now an urgent clinical governance need to either formally train physicians or abandon the concept and practice of general internal medicine-led temporary pacing, and devolve this to cardiologists.

To investigate whether a physiotherapy service to an EECU altered the rate of hospital admission, rate of re-presentation to the ED, visits to community healthcare practitioners, return to usual work/home/leisure activities and patient satisfaction.

A randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis was undertaken in an EECU. The sample comprised 186 patients (mean age 70 years, 123 (66%) female patients, 130 (70%) trauma) who were referred for physiotherapy assessment/intervention. Referral occurred at any stage of the patients' EECU admission. All participants received medical/nursing care as required. The physiotherapy group also received physiotherapy assessment/intervention.

The physiotherapy group had a 4% (95% CI –18% to 9%) lower rate of admission to hospital than the control group and a 4% (95% CI –6% to 13%) higher rate of re-presentation to the ED, which were statistically non-significant (p≥0.45). Differences between groups for use of community healthcare resources, return to usual work/home/leisure activities and satisfaction with their EECU care were small and not significant.

A physiotherapy service for EECU patients, as provided in this study, did not reduce the rate of hospital admission, rate of re-presentation to the ED, use of community healthcare resources, or improve the rate of return to usual work/home/leisure activities or patient satisfaction.

ANZCTRN12609000106235.

A combination of data sources was reviewed: a ‘realistic’ literature review, analysis of hospital episode statistics data from England and a local NHS trust audit.

LWBS rates vary across the world, from 15% to 0.36%. Also initiatives to reduce LWBS rates demonstrated mixed outcomes, with reductions in the rate by as much as 96%, while others were ineffective. The most common reason quoted for LWBS was long waiting times and there were few data to suggest LWBS posed a risk to patient health.

LWBS is an issue experienced in many countries that has responded in a varying manner to many initiatives in attempts to reduce it; however, it is clearly associated with the waiting times experienced in ED and therefore working within a packet of performance measures it would assess the effect of waiting times from another perspective.

A modified Laerdal manikin was connected to a Dragor ventilator (to measure intrathoracic pressures generated). The manikin was placed on a hospital trolley and CPR was performed by candidates at three different bed heights in a randomised order: (1) mid-thigh, (2) anterior superior iliac spine and (3) xiphisternum. Chest compressions were continuous and asynchronous with ventilation, and were allowed to continue for 30 s before recordings were taken. At the anterior superior iliac spine level, chest compressions were continued for 2 min, when further measurements were taken.

101 subjects took part. The differences in intrathoracic pressures generated at different bed heights were compared using analysis of variance testing for multiple groups and were statistically significant for p<0.05. The authors also found that the effectiveness of CPR decreased 17% over a 2-minute period (p<0.05).

The most effective bed height position, allowing CPR providers to achieve the highest intrathoracic pressures during CPR, was one where the patient's chest was in line with the CPR provider's mid-thigh. The provider performing CPR should change every 2 min.

Chart review of ED patients receiving remifentanil for procedural sedation in an urban general ED.

50 patients over a 28-month period with a mean age of 30.6 years (±2.6) were reviewed. Procedures performed included: abscess drainage (13); fracture care (9); thoracostomy (8); lumbar puncture (7); shoulder reduction (3); cardioversion (3) and others (7). Six (12%) cases received additional rescue medications. All procedures were successfully completed in the ED. No complications were recorded but 21 (42%) were admitted for underlying pathology.

Remifentanil is a safe and effective medication for ED use.

A cross-sectional study was performed on HCW in an emergency department (ED) in Botswana to determine the interrater reliability of triage acuity ratings when using PTS and PATS to assign triage categories to 25 written vignettes after PATS training. The intraclass correlation coefficient (ICC) was calculated to assess interrater reliability, and graphic displays were used to portray rating distributions for vignettes with a mean rating of different acuity categories for PTS and PATS.

44 HCW completed the scenarios. The ICC for the group of HCW was 0.52 (95% CI 0.37 to 0.67) using PTS and 0.87 (95% CI 0.80 to 0.93) using PATS. The ICC values were higher for PATS than PTS regardless of the number of years of experience of the HCW and the level of the HCW (specialist, medical officer, nurse, nurse aide). Graphic displays showed that there was less variability at all acuity levels when using PATS compared with PTS.

The reliability measures in this study indicate very high interrater agreement and limited variability in acuity ratings when using the PATS as opposed to moderate agreement and increased variability in acuity ratings when using PTS. This suggests that PATS is reliably applied by all levels of HCW and supports the feasibility of the further implementation of PATS in ED in Botswana and in other similar settings.

To determine communication preferences among survivors of motor vehicle crashes.

In this cross-sectional survey study, eligible participants included adult survivors of motor vehicle crashes in which there was a death, between 2005 and 2009. Participants were interviewed and responses to 30 questions about communication were recorded verbatim. Responses were coded and grouped for statistical analysis.

Among 26 eligible participants, 21 consented to participate (81% participation rate). Survivors' relationship to the deceased included spouse/significant other (33%), friend (24%), child (5%) and no relationship (38%). Survivors had been notified of the death in the prehospital setting (14%), in the emergency department (43%), or later in the inpatient setting (43%). Survivors were notified of the death by family members (43%), indirect communication (14%), police (10%), prehospital provider (10%), or friend (10%). Most participants (88%) had to ask directly to obtain information about the status of others in the crash. Participants demonstrated variable opinions about the ideal time of death notification: some recommended immediately (24%), in the emergency department (24%), in the inpatient setting (29%), or it depends on the circumstances (24%).

Survivors of motor vehicles crashes are notified of fatalities most commonly by family members, most commonly in the hospital setting. Recommendations from survivors about the appropriate timing and setting for death notification varied significantly.

To evaluate the effect of distributing DVD training kits to untrained laypersons. BLS skills were compared according to 2005 guidelines for resuscitation after 3.5 months with those obtained in untrained laypersons who completed the same course with instructor facilitation.

BLS skills of 55 untrained laypersons were assessed using the Laerdal ResusciAnne and PC Skill Reporting System in a 3 min test and a total score (12–48 points) was calculated. The participants received a DVD training kit without instructions. The test was repeated after 3.5 months. Data were compared with data from a previous published study where participants completed the same course in groups with instructor facilitation.

There was no statistically significant difference in the total score after 3.5 months. The ‘DVD—self-instructor’ group obtained 33 (29–37) points and the ‘DVD—with instructor’ group obtained 34 (32–37) points, p=0.16. The ‘DVD—with instructor’ group performed significantly better in checking responsiveness and had a significantly shorter ‘total hands-off time’ (s) (85 (76–94) vs 96 (82–120), p=0.002) and delay until first compression or ventilation group (29 s (17–40) vs 33 s (22–48), p=0.04).

Since no significant difference in total BLS score was found after 3.5 months between untrained laypersons who either completed a DVD-based BLS course in groups with instructor facilitation or received the same DVD training kit without instruction, the latter seems more efficient.

To derive a dispatch rule to reduce the need for L&S response by using MVC characteristics that could easily be described by a 9-1-1 caller. The US Centers for Disease Control Field Triage Guidelines were used as the standard for requiring L&S response; it was assumed that if a patient did not require transport to a trauma centre, he/she did not need an L&S response.

Data were extracted from prehospital patient care reports (PCRs) of patients transported by ambulance to a level I trauma centre between July 2007 and June 2008 with injuries sustained in MVCs. Patients with completed prehospital PCRs and hospital charts were included in the study. Five MVC characteristics were extracted that could easily be identified by a 9-1-1 caller. Using various permutations of these MVC characteristics, a dispatch rule was developed to determine when an ambulance should respond to an MVC without L&S. The sensitivity and specificity of this dispatch rule were calculated for both patients who met trauma centre triage criteria, and those who used trauma centre resources.

509 patients were included in the analysis. The following dispatch rule was developed for an ambulance response without L&S to a MVC: (1) the MVC does not occur on an interstate/highway, (2) and the MVC involves more than one car. AND (3) all patients are ambulatory. This dispatch rule was 95.9% sensitive and 33.5% specific for patients who met trauma centre criteria, and 97.7% sensitive and 32.5% specific for patients who required trauma centre resources. The study was limited by the large number of patients for whom prehospital PCRs were not available.

A simple three-step dispatch rule for MVCs can safely reduce L&S responses by one-third, as judged by need for transport to a trauma centre or use of trauma centre resources. Prospective validation is needed.

Data were obtained from the USA National Hospital Ambulatory Medical Care Survey of emergency department (ED) visits between 1998 and 2008. A cohort of atraumatic headache-related visits were identified using preassigned ‘reason-for-visit’ codes. Sample visits were weighted to provide national estimates.

Between 1998 and 2008 the percentage of patients presenting to the ED with atraumatic headache who underwent imaging increased from 12.5% to 31.0% (p<0.01) while the prevalence of ICP among those visits decreased from 10.1% to 3.5% (p<0.05). The length of stay in the ED was 4.6 h (95% CI 4.4 to 4.8) for patients with headache who received imaging compared with 2.7 (95% CI 2.6 to 2.9) for those who did not. Of 18 factors evaluated in patients with headache, 10 were associated with a significantly increased odds of an ICP diagnosis: age ≥50 years, arrival by ambulance, triage immediacy <15 min, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg and disturbance in sensation, vision, speech or motor function including neurological weakness.

The use of CT/MRI for evaluation of atraumatic headache increased dramatically in EDs in the USA between 1998 and 2008. The prevalence of ICP among patients who received CT/MRI declined concurrently, suggesting a role for clinical decision support to guide more judicious use of imaging.

559 consecutive patients with chest pain presenting to the ED and admitted for a suspicion of ACS were prospectively included. Predefined in-hospital complications were recorded and the risk predictions of the Global Registry of Acute Coronary Events (GRACE) risk score, the Freedom-from-Events (FFE) risk score and the Goldman rule were compared using receiver operating characteristics (ROC) curves.

Of the 559 patients, 140 had ACS and 32 had at least one complication. The GRACE score was superior to the FFE score in predicting the risk of complications (area under ROC curve 0.76 (95% CI 0.68 to 0.85) vs 0.69 (95% CI 0.60 to 0.79), p=0.021) whereas the Goldman rule (area under ROC curve 0.60; 95% CI 0.49 to 0.72) was inferior to both the GRACE and FFE scores. With the GRACE score set to a negative predictive value of 100% (95% CI 96% to 100%), 108 patients (19.3%) at almost no risk of complications could have been correctly identified in the ED.

The GRACE and FFE scores are able to predict low complication risks in patients with chest pain admitted for suspected ACS, but only the GRACE score may be able to identify a significant number of patients at almost no risk of complications. A larger multicentre study is needed to confirm the possibility of using the GRACE score to identify patients suitable for assessment without monitoring.

A prospective multicentre randomised study was performed enrolling resident physicians in emergency medicine from four hospitals in Asia. Participants were randomly assigned to a course that included didactic lectures followed by a skills workshop and simulated case scenario (lecture-first) or to a course that included a skills workshop and simulated case scenario followed by didactic lectures (simulation-first). A pre-test was given to the participants at the beginning of the course, post-test 1 was given after the didactic lectures or simulated case scenario depending on the study group assignment, then a final post-test 2 was given at the end of the course. Performance on the simulated case scenario was evaluated with a performance task checklist.

98 participants were enrolled in the study. Post-test 2 scores were significantly higher than pre-test scores in all participants (80.8±12.0% vs 65.4±12.2%, p<0.01). There was no difference in pre-test scores between the two study groups. The lecture-first group had significantly higher post-test 1 scores than the simulation-first group (78.8±10.6% vs 71.6±12.6%, p<0.01). There was no difference in post-test 2 scores between the two groups. The simulated case scenario task performance completion was 90.8% (95% CI 86.6% to 95.0%) in the lecture-first group compared with 83.8% (95% CI 79.5% to 88.1%) in the simulation-first group (p=0.02).

A medical simulation course can improve resident physician knowledge in the early management of severe sepsis. Such a course should include a comprehensive curriculum that includes didactic lectures followed by simulation experience.

A retrospective, observational analysis was performed of patients aged 16 years and older in the 2002–7 Ohio Trauma Registry. Those not initially transported by EMS or with incomplete EMS GCS scores were excluded. Outcomes included inhospital mortality, TBI, neurosurgical intervention, any emergency intubation and emergency department intubation. Discriminatory ability was compared using area under the receiver-operating characteristic curves (AUC). Sensitivity and specificity for each outcome were calculated at a SMS cutoff of one or less (any abnormal SMS) and a GCS cutoff of 13 or less.

52 412 patients were identified. Sensitivity, specificity and AUC were similar between the SMS and GCS for all outcomes. Sensitivity for mortality was 72.2% for SMS and 74.6% for GCS. Sensitivity for TBI was 40.8% for SMS and 45.4% for GCS. Sensitivity for neurosurgical intervention was 52.9% for SMS and 60.0% for GCS. Sensitivity for any intubation was 72.7% for SMS and 75.5% for GCS. Specificity was less than 2% different for all outcomes. Discriminatory ability was similar with the difference in AUC between SMS and GCS no greater than 6% for any outcome.

In a state trauma registry including both trauma and non-trauma centres, the EMS-obtained SMS performs as well as the 15-point GCS.

To determine the validity of a series of self-administered triage questions in determining the need for hospitalisation in the emergency setting.

Prospective cohort study.

Emergency department in a tertiary-care, municipal hospital in Japan.

5380 consecutive walk-in patients visiting the emergency department of Okazaki City Hospital were asked to self-evaluate the urgency and severity of their condition and their perceived need for hospital admission. These patients were then assessed by emergency physicians blinded to the results from each patient's self-assessment.

Sensitivity, specificity and likelihood ratios were calculated for each self-assessment by comparing these with findings from assessments made by emergency physicians.

Patient-perceived need for hospitalisation had a sensitivity of 0.79 (95% CI 0.76 to 0.82) and a specificity of 0.93 (95% CI 0.92 to 0.93) in determining hospital admission. The positive and negative likelihood ratios for self-assessments were 10.68 (95% CI 9.59 to 11.90) and 0.22 (95% CI 0.19 to 0.26), respectively, in the diagnosis of hospital admission (p<0.01).

The patient self-triage questions concerning condition with five categories (medication only to life threatening) seem to supplement the triage process for hospital admission in emergency departments.

A retrospective, multicentre study including all adult patients (ISS ≥9; 2002–7) of the Trauma Registry of the German Society of Trauma Surgery who were not secondarily transferred to a trauma centre and received a definitive airway and a chest tube. Creating four groups: AA (n=963) receiving ETI and chest tube on scene, AB (n=1547) ETI performed in the prehospital setting but chest tubing later in the emergency department (ED) and BB (n=640) receiving both procedures in the ED. The BA collective (ETI performed in the ED, but chest tubing on scene) was excluded from the study because of the small sample size (n=41). The trauma resuscitation time (TRT), demographic data, injuries, treatment and outcome of the remaining three collectives were compared.

The prehospital TRT of the AA collective was longer than the AB and BB subgroups (80±37 min vs 77±44 min 65±46 min; p<0.01). Although the AA and AB subgroups were more severely injured (ISS 35±15 vs 38±15 vs 31±12; p<0.01) and showed poorer vital parameters on scene, the overall TRT (accident until end of ED treatment) were equal for all three groups (152±59 min vs 151±62 min vs 148±68 min; p=0.07). The TRISS adjusted mortality was also equal in all three groups.

In a physician-based emergency medical service, prehospital ETI and chest tube placement do not prolong the total TRT of severely injured patients.

A postal questionnaire was devised and distributed to lead doctors of 245 ED in the UK in May 2010. Two further rounds of questionnaires were sent out in June and July to non-responders.

184/245 hospitals responded (75.1%). 41/184 (22.3%) ED had a WBCT policy. 43 (23.4%) further ED indicated that they used WBCT in certain cases, without a formal policy. Hospitals with a WBCT policy saw significantly more trauma cases than those that did not. Most hospitals with a WBCT policy used multiple criteria to decide which patients received WBCT, although there were variations in the timing of CT and in who could request it. Out-of-hours CT scans were less likely to be reported by a consultant radiologist, and reporting times were longer.

The use of WBCT in the UK is variable, although centres that see more trauma seem more likely to have a WBCT policy. The results do raise concerns about how effectively WBCT can be delivered, especially out of hours, but nationwide plans to reorganise trauma care may potentially affect how and at which ED WBCT is offered in the future.

All trauma-related dispatches of HEMS during a period of 6 months were included. Data concerning prehospital information and inhospital treatment were collected. Patients were divided into two groups (major and minor trauma) according to the following criteria: injury severity score 16 or greater, emergency intervention, intensive care unit admission, or inhospital death. Logistic regression analysis was used to design a prediction model for the early identification of major trauma patients.

In total, 420 trauma-related dispatches were evaluated, of which 155 concerned major trauma patients. HEMS was more often cancelled for minor trauma patients than for major trauma patients (57.7% vs 20.6%). Overall, HEMS dispatch criteria had a sensitivity of 87.7% and a specificity of 45.3% for identifying major trauma patients. Significant differences were found for vital sign abnormalities, anatomical components and several parameters of the mechanism of injury. A triage model designed for cancelling HEMS correctly identified major trauma patients (sensitivity 99.4%).

The accuracy of the current HEMS dispatch criteria is relatively low, resulting in high cancellation rates and low predictability for major trauma. The new HEMS cancellation triage model identified all major trauma patients with an acceptable overtriage and will probably reduce unjustified HEMS dispatches.

A retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the ‘triad of death’. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival.

There were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells.

There has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.

The authors included trauma patients who visited the emergency department, from 1 August 2009 to 31 July 2010, and searched for cases showing discrepancy using the ‘modified quality assurance model for radiological interpretation’. The overall/clinically significant discrepancy (CSD)/clinically insignificant discrepancy (CinSD) rates were calculated. The authors also looked at the relationship between discrepancies and several factors including age and time of visit.

10 243 cases were related to minor trauma, in which the radiological images were interpreted as normal by EPs. The overall discrepancy, the CSD and CinSD rates were 0.77% (n=79), 0.47% (n=48) and 0.3% (n=31), respectively. No discrepancy was shown to be related to the day or time of visit. The discrepancy rate turned out to be relatively higher with increasing age, and for injuries of the extremities. No associated factors were found between the CSD and CinSD groups.

Despite a relatively low CSD rate, careful interpretation is recommended considering age and body areas imaged. A modified model would be needed as a supportive tool for training and improving the quality of care. A further development of the modified system for efficient use of resources will be needed to focus on quality improvement and education in each hospital.

A 2-year retrospective cohort study was performed of all enquiries to the UK National Poisons Information Service involving BZD OD.

Flumazenil was administered to 80 patients in 4504 BZD-related enquiries, 68 of whom did not have ventilatory failure or had recognised contraindications to flumazenil. Factors associated with flumazenil use were increased age, severe poisoning and ventilatory failure. Co-ingestion of tricyclic antidepressants and chronic obstructive pulmonary disease did not influence flumazenil administration. Seizure frequency in patients not treated with flumazenil was 0.3%. The frequency of prior seizure in flumazenil-treated patients was 30 times higher (8.8%). Seven patients who had seizures prior to flumazenil therapy had no recurrence of their seizures. Ventilation or consciousness improved in 70% of flumazenil-treated patients. Flumazenil administration was followed by one instance each of agitation and brief seizure.

Flumazenil is used infrequently in the management of BZD OD in the UK. It was effective and associated with a low incidence of seizure. These results compare favourably with the results of published randomised controlled trials and cohort studies, although previous studies have not reported the use of flumazenil in such a high-risk population. This study should inform the continuing review of national guidance on flumazenil therapy.

To explore factors that influence the caller's decision to contact EMS at the onset of stroke, and the caller's experiences of the call.

Participants were identified through a purposive sample of admissions to two hospitals via ambulance with suspected stroke. Participants were interviewed using open-ended questions and content analysis was undertaken.

50 participants were recruited (median age 62 years, 68% female). Only one of the callers (2%) was the patient. Two themes were identified that influenced the initial decision to contact EMS at the onset of stroke: perceived seriousness, and receipt of lay or professional advice. Two themes were identified in relation to the communication between the caller and the call handler: symptom description by the caller, and emotional response to onset of stroke symptoms.

Many callers seek lay or professional advice prior to contacting EMS and some believe that the onset of acute stroke symptoms does not warrant an immediate 999 call. More public education is needed to improve awareness of stroke and the need for an urgent response.

Comparative design, using self-report questionnaires comparing emergency (n=73) and orthopaedic (n=63) staff. Measures included: General Health Questionnaire-12, Hospital Anxiety and Depression Scale, Brief COPE, and questions relating to social identity and social support.

The proportion of staff experiencing clinically significant levels of distress was higher than would be expected in the general population. The increased risk of psychological distress previously shown for emergency doctors is not present here for other emergency staff members. Better psychological health was associated with greater use of problem-focused coping and less use of maladaptive coping. Social support was associated with better psychological health and greater use of problem-focused coping.

Priority should be given to developing and evaluating interventions to improve psychological health for this group. Findings suggest that coping strategies and social support are important factors to incorporate into such interventions.

To explore factors associated with occupational stress among Chinese female emergency nurses

A cross-sectional study was conducted during April–May 2008. The study population consisted of 655 female emergency nurses from 16 hospitals in the Liaoning province, China. Occupational stress was measured by questionnaires that included the Chinese version of the Personal Strain Questionnaire, and data were collected on respondents' demographic characteristics, work situations, occupational roles and personal resources. A total of 510 effective respondents comprised our study subjects (response rate 77.9%). A general linear model was applied to analyse the factors associated with occupational stress.

The mean Personal Strain Questionnaire score of the emergency nurses was 91.2 and this score was correlated, in descending order of standardised estimate, with role overload, role boundary, role insufficiency, social support, chronic disease and self-care.

The factors role overload, role boundary and role insufficiency had the highest association with occupational stress. Improving work conditions and providing health education and an occupational training programme might help to reduce occupational stress among Chinese female emergency nurses.

A prospective study of all DNW patients was performed from 1 January to 31 December 2008. Following a daily review of charts of those who failed to wait to be seen, those patients considered to be at risk of adverse outcome were contacted by the liaison team and advised to return. Data were gathered on all DNW patients on the Oracle database and interrogated using the Diver solution.

2872 (6.3%) of 45 959 patients did not wait to be seen. 107 (3.7%) were recalled on the basis of senior emergency medicine doctor review of the patients' triage notes. Variables found to be associated with increased likelihood of being recalled included triage category (p<0.001), male sex (p<0.004) and certain clinical presentations. The presenting complaints associated with being recalled were chest pain (p<0.001) and alcohol/drug overdose (p=0.001). 9.4% of DNW patients required admission following recall.

The systematic senior doctor review of triage notes led to 3.7% of patients who failed to wait being recalled. 9.4% of those recalled required acute admission. The daily review of DNW patients' triage notes and the recalling of at-risk patients is a valuable addition to our risk management strategy.

The review used a ‘conceptual synthesis’ approach to identify knowledge and opinion around the issue of ED crowding, not just effective interventions. Recommendations from the literature were classified according the quality of evidence and the extent to which they were under ED control.

SCOPUS and ISI were searched for studies of ‘ED’ AND ‘crowding OR overcrowding’ and backward citation retrieval was undertaken. To help identify systematic review evidence of effective interventions, the Cochrane Database, the National Institute of Health and Clinical Excellence (NICE) and NHS Evidence were searched. A Google search was included to identify relevant grey literature.

Papers were included if they added to substantive knowledge of ED crowding. Empirical studies, studies from the UK and studies of physical space were privileged in the review.

There is an established international literature on ED crowding. It suggests consistently that crowding has significant negative consequences. However, the literature offers limited practical help to practitioners for a number of reasons, such as a lack of shared definition and measurement of crowding and lack of evaluation of interventions. Many studies are single case studies from the USA.

While current evidence is poor, this does not justify maintaining current practice which risks lives. Building up an evidence base is critical, but requires agreed definitions, measures and methods, which can be applied to systematic evaluation of plausible solutions.

This was a prospective diagnostic cohort study. Inpatients and ED patients >16 years of age investigated for PE or DVT at a single hospital were eligible for study consent. Blinded IMA analysis was performed on the first blood sample taken from each patient. Patients underwent reference standard investigation for PE or DVT, including 3-month follow-up. Receiver operating characteristic (ROC) curves were constructed for IMA and the IMA:albumin ratio in the diagnosis of all VTE, PE and DVT. A sensitivity analysis was performed.

452 patients were consented and investigated for DVT, and 354 patients were consented and investigated for PE (806 in total). 348 patients investigated for PE had IMA testing as did 195 of the first 199 DVT patients. VTE prevalence was 19.7%. The IMA:albumin ratio performed better than IMA alone. The area under the ROC curve (AUC) for IMA:albumin in all VTE was 0.60 (95% CI 0.54 to 0.66), in DVT 0.56 (95% CI 0.46 to 0.65) and in PE 0.63 (95% CI 0.56 to 0.71). In ED patients with symptoms of PE, the AUC for IMA:albumin was 0.69 (95% CI 0.60 to 0.78).

IMA testing cannot be used alone to diagnose DVT or PE, although there is a moderate association with PE in ED patients.

A group of soldiers of the International Security Assistance Force participated in a training programme for the use of the FAST-1 intraosseous infusion system. To demonstrate the application of this device, a FAST-1 needle was...]]> 2011-06-02T20:49:33-07:00 info:doi/10.1136/emermed-2011-200139 hwp:master-id:emermed;emermed-2011-200139 British Association for Accident and Emergency Medicine 2011-06-02 Reflections on prehospital care http://emj.bmj.com/cgi/content/short/emj.2010.102855v1?rss=1 Objectives

To evaluate whether single-channel electroencephalography (EEG) recording can be conducted in the out-of-hospital setting and whether it can be used to record electrographic signs of convulsive epileptic seizures.

This prospective observational feasibility study included patients who presented with a recent or ongoing epileptic seizure during out-of-hospital emergency treatment. Bifrontal single-channel EEG recordings were conducted by ambulance physicians throughout the initial treatment. The data recorded were analysed for the quality of recording and the occurrence of ictal EEG patterns.

There were 45 adult patients who had a recent or an ongoing epileptic seizure in the study group and 15 patients with no neurological disorders in the control group. The median percentage of time during which no artefacts were detected by the device was 88.0% in the study group and 96.0% in the control group. EEG recordings for 3 out of 45 (6.6%) patients were of poor quality and not evaluable. Spike/wave or polyspike patterns were found in 98% and 100% of patients in the study and control groups, respectively, whereas the occurrence of periodic epileptiform discharges and delta waves with spikes showed a sensitivity and specificity of 100% (10/10) for the presence of an ongoing epileptic seizure.

Single-channel EEG can be performed outside the hospital and yields useful recordings in most patients with acceptable rates of artefact. The diagnosis of generalised convulsive epileptic seizures by offline analysis of out-of-hospital EEG showed a high sensitivity and specificity when compared with the clinical diagnosis.

To evaluate the effectiveness of local cold application on reducing the incidence, severity and pain/sensitivity of skin burns in patients who underwent TTC.

The study was conducted in the intensive care unit of the cardiovascular surgery department. The patients were assigned to study (n=24) and control groups (n=24). Local cold application was performed for a 1 hour period on patients in the study group, whereas only clinical procedures were applied in the control group following TTC. Incidence and severity of burn was evaluated 2 h after TTC, and pain/sensitivity scores were evaluated at 2, 4 and 24 h after TTC.

The incidence of burn was significantly lower in the study group (3/24) compared to the control group (21/24) (12.5% vs 83.3%, p<0.001). Pain/sensitivity scores were significantly lower in the study group compared to the control group (p<0.05).

Local cold application following TTC is an effective means of reducing the incidence and severity of burns and pain/sensitivity. It is cost-effective and can easily be applied by nurses in medical/surgical units and emergency departments.

An observational cohort study of all head injured patients aged 13–21 and in full-time education presenting to an inner city ED was performed. Subjects were followed up at 1 and 6 months after injury by structured telephone interview to assess for the presence of symptoms or ongoing disability. Presentation data of those identified as having PCS underwent regression analysis to isolate potential prognostic indicators for such problems.

Of the 188 patients recruited, 5.9% (95% CI 3.3% to 10.2%) still had some symptoms after 6 months, with half of these claiming that such symptoms were affecting everyday living. Of these patients, 82% were assaulted as the cause of their injury and nearly 40% had no conventional indicators of head injury severity at presentation. After 1 month, 46/188 (24.5%, 95% CI 18.9% to 31.1%) patients had some degree of symptoms, most of whom were discharged directly from the ED. Potential prognostic indicators identified were a reduced Glasgow Coma Score (GCS) (<15) at presentation and being assaulted as the cause of injury.

The prevalence of PCS 6 months following head injury for the selected sub-group was 5.9%, and 10.6% if assaulted. Most patients who developed PCS were discharged directly from the ED.

To evaluate the introduction of an ICP on process of care of the paracetamol poisoned patient.

A retrospective case note review of consecutive patients admitted to the Royal Infirmary of Edinburgh following a paracetamol overdose was conducted. Data were collected for a 3-month period before and after introduction of the ICP to the emergency department and toxicology inpatient unit.

The ICP was used in 77% of cases in the time period studied and was associated with improvements in initial documentation of patient assessment (pre-ICP vs post-ICP: 87/161 (54%) vs 101/113 (89%), p<0.0001) and appropriateness of blood sampling (146/161 (91%) vs 111/113 (98%), p=0.01), but no change in timely blood sampling (pre 124/161 (77%) vs post 93/113 (82%)). All aspects of intravenous acetylcysteine administration also significantly improved: administration of acetylcysteine if indicated (pre-ICP vs post-ICP: 57/71 (80%) vs 71/71 (100%), p<0.0001); acetylcysteine commenced in a timely fashion (33/71 (46%) vs 55/71 (77%), p=0.0002); and acetylcysteine correctly prescribed (44/58 (76%) vs 71/71 (100%), p<0.0001).

Implementation of an ICP for paracetamol poisoning significantly improved patient management and helped to standardise inter-professional decision making in this challenging patient group. This is likely to improve patient outcome.

Data were collected in a type 1 urban ED over a 2-month period in two stages: questionnaire to adult attendees presenting to the ED; and a notes review.

The usable response rate was 68% (n=261/384). The notes review confirmed that more than two-thirds of the presenting conditions could have been managed in settings other than the ED. The attendees' reasons on the questionnaire indicated a strong belief that the only provider able to deal with their concerns at that time was the ED. For some users, the ED was not the first contact with a healthcare provider for the same health problem. Few believed that they would be seen quicker in the ED or that the ED was more convenient. The most frequent reason for presenting to the ED was ‘being advised to attend by someone else’. The ‘adviser’ was more likely to be a health professional (doctor or nurse or NHS Direct) than to be ‘friends or family’.

Although there appears to be considerable potential for minor conditions to be managed in settings other than the ED, our findings indicate that patients will continue to present these conditions to the ED. Patient perceptions of the urgency of their treatment need, and also the availability and capacity of alternative services may be offsetting their potential to substitute for the ED. Advice from other services may be contributing to demands on the ED.

This prospective inception study enrolled patients aged 14 years and older presenting with acute intoxication between January 2006 and April 2008 to a Dutch university hospital. An algorithm was developed based on a previous retrospective study and the medical literature. In a second algorithm the clinical course during the stay in the ED was also taken into account.

Of 313 patients presenting with acute intoxication to the ED, 134 (42.8%) were admitted to a ward for somatic care, but only 74 (23.6%) were treated on the ward. Algorithm 1 had 91.9% sensitivity (95% CI 82.6% to 96.7%) and 53.6% specificity (95% CI 47.0% to 60.0%). Algorithm 2 had 90.5% sensitivity (95% CI 80.9% to 95.8%) and 65.3% specificity (95% CI 58.8% to 71.2%). In line with hospital policy, several patients received N-acetylcysteine treatment for subtoxic paracetamol ingestion because they presented outside of office hours, when no measurements of blood paracetamol concentration are performed by the laboratory. When these patients are considered as untreated, both algorithms had 98.5% sensitivity (95% CI 90.6% to 99.9%).

The algorithms had good sensitivity and better specificity than current clinical practice in most hospitals. It is too early to advocate their implementation, but results indicate that it is possible to use clinical parameters objectively to reduce unnecessary admissions to the ward.

To compare US-JVD and initial BNP levels in patients with dyspnoea.

This was a secondary analysis of a previously collected dataset from a prospective study of US-JVD in patients with dyspnoea due to suspected congestive cardiac failure. Initial BNP levels were obtained for each patient. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios (LR) of US-JVD ≥8 cm H₂O for BNP ≥500 pg/ml were calculated. The product moment correlation coefficient between US-JVD and BNP was also calculated.

119 patients were included in the initial study. US-JVD ≥8 cm H₂O had a sensitivity of 100% (95% CI 92% to 100%), specificity of 43% (95% CI 31% to 56%), PPV of 61% (95% CI 50% to 71%), NPV of 100% (95% CI 84% to 100%), LR+=1.75 (95% CI 1.41 to 2.17), and LR–=0 for a BNP ≥ 500 pg/ml. The Pearson correlation coefficient between US-JVD and BNP was 0.35 (95% CI 0.18 to 0.50) and the Spearman correlation coefficient was 0.73 (95% CI 0.63 to 0.80), suggesting a monotonic, but non-linear relationship between US-JVD and BNP.

US-JVD correlates with initial BNP levels and is a sensitive test for raised BNP levels in patients with dyspnoea due to suspected congestive cardiac failure.

An observational study over 24 h, of patients who presented to 15 public ED during the 3-month period from 1 October to 31 December 2010. The study was conducted across Kenya in two national referral hospitals, five secondary level hospitals and eight primary level hospitals. All patients presenting alive to the ED during the 24-h study period that were seen by a doctor or clinical officer were included in the study. A data collection form was completed by the primary investigator at the time of the initial ED consultation documenting patient demographics, presenting complaints, investigations ordered, procedures done, initial diagnosis and outcome of ED consultation.

Data on 1887 patient presentations were described. Adults (≥13 years) accounted for the majority (70%) of patients. Two peak age groups, 0–9 and 20–29 years, accounted for 27% and 25% of patients, respectively. Respiratory and trauma presentations each accounted for 21% of presentations, with a wide spread of other presentations. Over half (58%) of the patients were investigated in the department. 385 patients received immediate treatment in the ED before discharge. Fewer than one in three patients admitted or transferred to specialist units received any therapy in the ED.

ED in Kenya provide care to an undifferentiated patient population yet most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients have to await transfer to wards or specialist units to start receiving treatment.

This was a secondary analysis of a previously reported prospective study of ultrasonography for SBO. Patients with prior abdominal surgery were identified and presenting signs and symptoms were compared to the CT diagnosis of SBO.

No signs or symptoms were predictive of SBO.

No constellation of signs and symptoms can be used to reliably exclude a SBO in patients with prior abdominal surgery.

The CIP intervention area was compared with the non-intervention area in order to determine whether there was a statistically significant improvement in KPI results.

The CIP was associated with a statistically significant improvement in paramedic KPI results within the intervention area.

The strategies used within this CIP are recommended for further consideration.

Questionnaire made available to members of selected Scandinavian medical societies.

Of 759 responders to the questionnaire, 23.5% (n=178) had experienced one or more situations where there was a need for IO but none was placed. The most common stated reasons for not performing IO were a lack of equipment (48.3%), a lack of knowledge about the procedure (32.6%), and intravenous access preferred over IO (23.0%).

The main reasons for not using IO were lack of equipment and lack of training. The authors recommend increased training in IO use and greater availability of IO equipment for front-line staff in Scandinavian countries. The use of non-purpose-designed needles for IO should be evaluated.