The aim of this study is to map and evaluate the available resources and the premises of traumatic head injury management in the Nordic countries, before the implementation of a Nordic adaption of the Brain Trauma Foundation guidelines for prehospital management.
The study is a synthesis of two cross-sectional surveys. Questionnaires were used to collect data on the annual number of acute head injury operations, the infrastructure, the level of education, the use of trauma protocols and the management of traumatic head injury at Nordic hospitals.
The proportion of acute head injury operations performed outside a neurosurgical department was 0% in Denmark, 16% in Finland, 19% in Norway and 33% in Sweden. Eighty-four per cent of Nordic hospitals had written protocols for the assessment and treatment of trauma patients and 78% had regular training in trauma management; 67% had specific protocols for the treatment of traumatic head injury. Computed tomography (CT) was available in 93% of the hospitals, and 59% of the hospitals could link CT scans to the regional neurosurgical department.
Most Nordic hospitals are well prepared to manage patients with acute traumatic head injury. A substantial proportion of the operations are performed at local and central hospitals without neurosurgical expertise, despite an efficient pre and interhospital transport system. The Nordic adaption of the Brain Trauma Foundation guidelines recommends that this practice is terminated.
To improve the care of patients presenting to the emergency department who are acutely dying or those in whom further disease-modifying treatment is not appropriate.
A quality improvement report on the implementation of a modified Liverpool Care Pathway for the Dying Patient (LCP) in an emergency medicine department.
The emergency medicine department of Ninewells Hospital, Dundee. Ninewells Hospital is the tertiary referral and teaching hospital for the east coast of Scotland and North East Fife.
The pathway was introduced after a 2001 study and a 2003 audit showed that the department had an increasing role in the care of the acutely dying, but some inconsistency in approach. Key measures for improvement were to improve communication between staff, improve the consistency of care and improve the perceived quality of care given. Senior decision making remains a crucial element of the pathway.
A modified LCP was developed and launched in November 2005. Change was managed via a series of meetings and a pilot process. Serial review and audit allowed ongoing quality review of the pathway and improvements.
The care of the dying patient has become a more consistent and positive endeavour. Nursing staff are very satisfied with its use, and it is hoped that the LCP pathway can be developed further within the organisation.
It has been a rewarding undertaking to improve the care of dying patients, but one which has taken time and has required consistent management of change to promote the positive outcomes.
Patients who fail to wait for medical assessment in the emergency department (ED) have been referred to in the international literature as "did not wait" (DNW) or "left without being seen" (LWBS) patients or, indeed, simply as "walkouts". This is taken as a performance indicator internationally. In common with many countries, Ireland has very considerable problems in the delivery of ED care due largely to inadequate resources and the inappropriate use of EDs as holding bays for admitted patients. This is the first study of this size to profile the DNW phenomenon in Ireland.
The charts of DNW patients were identified and the DNW status was entered into the ED computer record. Data concerning age, sex, time of arrival, date of arrival, triage category and presenting complaint were recorded.
In the study period there were 11 662 patient attendances, of whom 871 patients (7.47%) did not wait for assessment. Triage category was highly statistically significant, with those in the lowest triage category having the highest numbers not waiting to be seen (p<0.001). Those attending at night (p<0.001) and at the weekend (p = 0.03) were most likely to leave without being assessed.
Failure to provide the service in a timely manner gives rise to patients leaving without receiving the medical assessment they came to obtain. This is a serious clinical problem and puts both those requiring care and those providing it at risk of adverse outcomes.
A recent meta-analysis showed that intravenous and nebulised magnesium sulphate have similar levels of evidence to support their use in the treatment of acute asthma in adults. This consisted of weak evidence of effect on respiratory function and hospital admissions, with wide confidence intervals ranging from no effect to significant positive effects. Current BTS/SIGN guidelines suggest an equivocal role for intravenous magnesium sulphate and no role for nebulised magnesium sulphate. A study was performed to assess what emergency physicians currently do in their management of acute asthma.
A postal survey was undertaken of all adult emergency departments within the UK. A structured questionnaire was sent to all clinical leads in emergency medicine about their current usage of both intravenous and nebulised magnesium sulphate in the treatment of acute asthma.
180 of the 251 emergency departments in the UK responded (72%). Magnesium sulphate was used in 93%, mostly because it was expected to relieve breathlessness (70%) or reduce HDU/ITU admissions (51%). It was predominantly given to those patients with acute severe asthma (84%) and life-threatening exacerbations (87%), with most stating they would give the drug if there was no response to repeated nebulisers (68%). In comparison, nebulised magnesium sulphate was only used in two emergency departments (1%). The main reason for not administering the drug via a nebuliser was insufficient evidence (51%).
Intravenous magnesium sulphate is widely used for acute asthma, usually for patients with severe or life-threatening asthma who have not responded to initial treatment. Nebulised magnesium sulphate, by contrast, is hardly used at all. The use of intravenous magnesium sulphate is more extensive than current guidelines or available evidence would appear to support.
Effective preparedness for pandemic influenza necessitates acquisition and maintenance of vital equipment and infrastructure. The aim of this study was to investigate the relationship between the level of hospital preparedness relating to infrastructure and equipment and performance of the hospital in an avian flu drill.
The levels of preparedness of the infrastructure and equipment for pandemic influenza of all 24 general hospitals were evaluated using a tool developed for this purpose. The hospital evaluation scores were then compared with the scores obtained by the hospitals in a simulated avian flu drill.
The overall scores of equipment and infrastructure for pandemic influenza of general hospitals ranged from 67% to 100%. Comparison of the overall level of preparedness of equipment and infrastructure for pandemic influenza with the overall scores achieved in the avian flu drill revealed a medium correlation. A medium correlation was also found between stockpiling of medications and performance in the avian flu drill. No correlations were found between operating infrastructure, availability of protective measures and medical forms and performance in the avian flu drill.
This study has identified benchmarks of infrastructure and equipment required for managing a pandemic influenza event and evaluating the level of emergency preparedness of the hospital. The significant relationship between maintaining stockpiles of antiviral medications for patients and staff and performance in an avian flu drill emphasises its importance in the process of maintaining emergency preparedness for a pandemic influenza outbreak.
In patients with acute chest pain, we derived a cutpoint for ischaemia-modified albumin (IMA) and prospectively validated this cutpoint to predict 30-day major adverse cardiac events (MACEs).
We prospectively recruited a derivation cohort (18-month period) to establish a serum IMA cutpoint targeting 80% sensitivity. This was followed by a prospective validation cohort study of emergency department patients with acute chest pain at two university hospitals over a 3-month period. A MACE was defined as myocardial infarction, revascularisation or death at 30-day follow-up.
In the derivation cohort of 151 patients, the IMA cutpoint that achieved 80% sensitivity for MACEs was 75 KU/litre. The sensitivity was prospectively validated in 171 patients consecutively enrolled, of whom 106 underwent multiple-biomarker analysis (19.8% MACE rate, 81% sensitivity of IMA). Furthermore, IMA by itself (81%, p<0.01) and in combination with initial highly sensitive cardiac troponin T (hsTnT) (90%, p<0.001) had significantly higher sensitivity than initial hsTnT (29%) for prediction of MACEs.
We prospectively validated the sensitive IMA cutpoint of 75 KU/litre with 80% sensitivity for MACEs in patients with acute chest pain. Our data suggest that IMA alone and in combination with initial hsTnT are more sensitive than the initial hsTnT for MACEs.
The previously mobile child who refuses to walk or weight-bear is a common presentation to the accident and emergency department, for which there are a number of causes. One uncommon cause is discitis, an inflammatory process of the intervertebral disc, which is easily diagnosed with spinal magnetic resonance imaging (MRI). A case series of three patients is presented of non-weight-bearing children in whom there was a delay in making the diagnosis of lumbosacral discitis. None presented with back pain, spinal symptoms or abnormal neurological findings, and a full range of movement of both hips was found.
All patients underwent conventional radiography and ultrasound, but diagnoses were made on spinal MRI, with two patients undergoing bone scintigraphy before this.
The mean delay was 15.6 days (range 13–20) from presentation at the hospital to MRI. All three patients made a good clinical recovery with intravenous antibiotics.
These cases are presented in order to heighten the awareness of this disease entity and its imaging findings, and suggest new guidelines for the appropriate radiological investigations in this clinical setting.
The purpose of this study was to identify independent factors that can be used to predict whether febrile neutropenic patients who appear healthy at presentation will develop subsequent complications, using variables that are readily available in the emergency department (ED).
The medical records of 192 episodes in which the patients presented to the ED with neutropenic fever resulting from chemotherapy, with an alert mental state and haemodynamic stability were retrospectively reviewed. Endpoints examined were fever response to administered antibiotics, death or severe medical complications during hospitalisation.
Thirty-eight episodes of neutropenic fever with complicated outcomes were identified from among a total of 192 episodes. Three parameters emerged as independent factors for the prediction of neutropenic fever with complications in the multivariate regression analysis: platelet count (130–450 x 103 cells/mm3) <50 000 cells/mm3, serum C-reactive protein (CRP, 0.1–1 mg/dl) >10 mg/dl and pulmonary infiltration on chest x ray.
Platelet count, CRP and pulmonary infiltration on chest x ray at presentation could be used to identify febrile neutropenic patients who will develop complications, and these factors may be useful in making treatment-related decisions in the ED.
The correct chest compression technique was emphasised to enhance the result of cardiopulmonary resuscitation in the 2005 guidelines. The present study compared the effects of different bed heights, including a bed at knee height, on the performance of chest compressions.
Twenty-four healthcare providers participated in this study. Knee height was defined as the baseline bed height. Bed heights were adjusted to 10 and 20 cm above the baseline and 10 and 20 cm below the baseline. At the five bed heights, chest compressions were performed for 2 minutes, and the compression rate was maintained at 100 per minute, with audible feedback.
The mean compression depths (MCD) were 28.3 mm (SD 10.7; knee height +20 cm), 32.3 mm (SD 9.2; knee height +10 cm), 32.7 mm (SD 8.5; knee height), 32.3 mm (SD 9.0; knee height –10 cm) and 31.1 mm (SD 8.5; knee height –20 cm). The MCD was significantly lower at knee height plus 20 cm (p<0.001).
The performance of chest compressions decreased when the bed height was 20 cm higher than the knee height of the rescuer.
Data from mass gathering events help when planning allocation of resources and in setting standards of care. There is currently a lack of data from the UK.
To determine the frequency of injuries and hospital transfer rates at a large outdoor endurance event.
251 patient attendances from four consecutive events over 2 years (two summers two winters; 2006–2007) were analysed.
1%–2% of contenders required medical help. Hypothermia (n = 84), soft tissue problems (n = 71) and musculoskeletal problems (n = 51) were the most common conditions encountered. 4% of patients required immediate transfer to the hospital. The medical team was able to prevent 31 hospital transfers, which represents a reduction of 78%. 13% of cases specifically required a doctor who was able to prevent more immediate hospital transfers than other care givers. The majority of injuries were classified as minor (n = 228), with the remaining as intermediate (n = 23); there were no life-threatening injuries or deaths. No patient required intravenous fluid. Overall, in winter, more patients were treated when compared with summer (157 vs 94). There were significantly more retirements in winter (69 vs 22, p<0.001), although hospital transfer rates were similar.
Medical teams should plan for casualty rates of 1%–2% of competitors and hospital transfer rates of ~5% of patients treated. Outdoor events in winter create more casualties than in summer and require greater resources. Trauma and exposure injuries are common; critical illness is uncommon. An adequately equipped and skilled medical team reduces hospital admissions.
Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique.
We used a non-randomised control group design, comparing two counties in the East Midlands (UK) as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a "model" arm using a predesigned checklist.
There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p<0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p<0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p<0.001).
The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation.