Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,
We do not disagree with the comment, hence our conclusion that, “CT is a valid first line imaging technique in suspected occult hip fracture and is easily accessible in most centres.” The intention of the BET was to present evidence on whether one modality was better than the other and so we looked for studies comparing the two imaging techniques. The study by Thomas et al. forms part of the evidence that CT scanning is a valid method of detecting occult hip fractures and so was not included in the table of evidence.
Thomas RW, Williams HLM, Carpenter EC, Lyons K. The validity of investigating occult hip fractures using multidetector CT. Br J Radiol
I read this article with interest as I am currently launching a QUIP on this exact subject.
As a declaration of possible bias I am looking to use highly sensitive CTs to screen off negative findings to frailty services and thus avoiding orthopaedic beds.
I am surprised that more credence was not given to the study by Thomas et al. who's sensitivity and specificity was 100% for ct. The study is one that clearly identifies MDCT as the protocol of choice when identifying occult hip fractures. I am not sure whether this is directly comparable to other studies in this way, and therefore some doubt exists as to whether current discrepancies in reporting are more attributable to the scanning protocol used.
I feel that the current nice guidelines are out of date with modern CT scanning and is having undue influence on first line diagnostics of occult hip fractures.
I do appreciate the move forward for CT scanning hips as first line diagnostics thus cutting bed-days/patient, expediting correct treatment and improving patient experience.
The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
References
(1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
Blood pressure measurement in the Post-SPRINT Era
Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
(2)Giles TD., Egan P
Inter-arm differences in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Giles TD., Egan P
Inter-arm dif...
The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
References
(1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
Blood pressure measurement in the Post-SPRINT Era
Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
(2)Giles TD., Egan P
Inter-arm differences in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Giles TD., Egan P
Inter-arm differenc in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(3)Hanazawa T., Asayama K., Watabe D et al
Association between amplitude of seasonal variation in self measure home blood pressure and cardiovascular outcomes: HOME-BP Study
Journal of the American Heart Association2018;7:e008509. DOI:10.1161/JAHA.117.008509..
We read with interest the recent article by Setala et al, where active compression decompression cardiopulmonary resuscitation (ACD-CPR) was compared with manual CPR. 1 In this study, to ensure continuous high-quality resuscitation, an audiovisual feedback defibrillator (Zoll X Series, Real CPR Help, ZOLL Medical Corporation, USA) was used. This is a key element for cardiac arrest studies. It is known that quality of CPR is an important modifier in cardiac arrest studies. 2 High-quality CPR is necessary to be able to compare and generalize the results. There is, however, a major methodologic flaw in the Setala et al study. None of the accelerometers used in feedback defibrillator are adapted to analyze ACD-CPR. The issue arises from the fact that the accelerometers are designed to measure only one distance from the chest resting point at the end of the passive decompression to the compression maximum depth. In the Setala et al study, there was no difference in distance between groups 76 (SD 1.3) mm versus 71 (SD1.0) mm. However, in ACD CPR, you need active compression (5 cm) combined with active decompression (3 cm or 15kg of pulling). Given the reported data, there are two distinct possibilities. The first is that Setala et al were able to perform active decompression (rising the chest higher than the chest resting point) but that their compressions were not adequately deep enough. As a result, ETCO2 would be lower compared to CPR with high-quality compression. The second...
We read with interest the recent article by Setala et al, where active compression decompression cardiopulmonary resuscitation (ACD-CPR) was compared with manual CPR. 1 In this study, to ensure continuous high-quality resuscitation, an audiovisual feedback defibrillator (Zoll X Series, Real CPR Help, ZOLL Medical Corporation, USA) was used. This is a key element for cardiac arrest studies. It is known that quality of CPR is an important modifier in cardiac arrest studies. 2 High-quality CPR is necessary to be able to compare and generalize the results. There is, however, a major methodologic flaw in the Setala et al study. None of the accelerometers used in feedback defibrillator are adapted to analyze ACD-CPR. The issue arises from the fact that the accelerometers are designed to measure only one distance from the chest resting point at the end of the passive decompression to the compression maximum depth. In the Setala et al study, there was no difference in distance between groups 76 (SD 1.3) mm versus 71 (SD1.0) mm. However, in ACD CPR, you need active compression (5 cm) combined with active decompression (3 cm or 15kg of pulling). Given the reported data, there are two distinct possibilities. The first is that Setala et al were able to perform active decompression (rising the chest higher than the chest resting point) but that their compressions were not adequately deep enough. As a result, ETCO2 would be lower compared to CPR with high-quality compression. The second is that Setala et al did not perform true active decompression but rather they performed high-quality compressions guided by an accelerometer. However, in the absence of decompression, they are likely comparing the same intervention. The only way to guide ACD-CPR is by using the gauge present in the Cardiopump (Zoll). However, this strategy was not employed by the authors of the study. Therefore, the authors cannot say that they realize “quality-controlled resuscitation” due to the presence of this technical limit of accelerometers.
Furthermore, large studies followed by a meta-analysis encompassing 4162 participants were not able to demonstrate the benefit of ACD-CPR versus manual CPR for mortality either at the time of arrest or at hospital discharge. 3 It is unlikely that the study by Setala et al with 10 participants could demonstrate a significant difference not previously identified in larger studies. To be effective, ACD CPR needs circulatory enhancement with an Impedance Threshold Device (ITD). 4 The combination of ACD + ITD-CPR has demonstrated its' ability to increase blood flow to the heart and brain as well as improving survival with favorable neurological outcomes.
Understanding the physiology behind these “Do’s and Don’ts" with active compression decompression CPR is critical to the improvement of resuscitation. Moreover, there must be a larger realization that ACD + ITD CPR requires implementation into an established systems-based approaches to cardiac arrest care. There are no silver bullets in resuscitation; ACD CPR alone during resuscitation cannot and will not improve neurological outcomes.
References
1. Setala PA, Virkkunen IT, Kamarainen AJ, Huhtala HSA, Virta JS, Yli-Hankala AM, et al. End-tidal carbon dioxide output in manual cardiopulmonary resuscitation versus active compression-decompression device during prehospital quality controlled resuscitation: a case series study. Emerg Med J 2018;35:428-32.
2. Yannopoulos D, Aufderheide TP, Abella BS, Duval S, Frascone RJ, Goodloe JM, et al. Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation 2015;94:106-13.
3. Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev 2013;9:CD002751.
4. Lurie KG, Nemergut EC, Yannopoulos D, Sweeney M. The Physiology of Cardiopulmonary Resuscitation. Anesth Analg 2016;122:767-83.
We applaud the authors for their effort to educate the bystander and even medical professionals with a means to provide care for the injured in terrorist attacks. While the majority of the information provided is based in historical evidence, in today’s era of superior wound packing materials the use of tampons for gunshot wounds (GSWs) is an inferior and dangerous suggestion.
Tampons have been around for many thousands of years for vaginal bleeding, but nothing has been documented for their use in GSWs.[1] Stories of tampon use have been around since the Vietnam era. There have even been anecdotes posted on Snopes.com from the war in Iraq.[2] The story is full of unsubstantiated information, yet it is a common reference for many.
One can find in the fringe of the Internet, other claims of tampon effectiveness. Bioprepper claims tampons are “designed to be ultra-absorbent” and “can be used to plug a bullet hole until…accounts of this use date back to World War I.”[3] They go on to say, “Many items in modern society were first developed as a facet of military research – tampons being a prime example.” This is absolutely false. Not only that the article itself never demonstrates a tampon being used to stop life threatening hemorrhage – rather it illustrates a plethora of Boy Scout novelties of the tampon.
Elsewhere, there are anecdotes of tampons being used during World War I and II, but nothing specifically written from the era. Still, there is no def...
We applaud the authors for their effort to educate the bystander and even medical professionals with a means to provide care for the injured in terrorist attacks. While the majority of the information provided is based in historical evidence, in today’s era of superior wound packing materials the use of tampons for gunshot wounds (GSWs) is an inferior and dangerous suggestion.
Tampons have been around for many thousands of years for vaginal bleeding, but nothing has been documented for their use in GSWs.[1] Stories of tampon use have been around since the Vietnam era. There have even been anecdotes posted on Snopes.com from the war in Iraq.[2] The story is full of unsubstantiated information, yet it is a common reference for many.
One can find in the fringe of the Internet, other claims of tampon effectiveness. Bioprepper claims tampons are “designed to be ultra-absorbent” and “can be used to plug a bullet hole until…accounts of this use date back to World War I.”[3] They go on to say, “Many items in modern society were first developed as a facet of military research – tampons being a prime example.” This is absolutely false. Not only that the article itself never demonstrates a tampon being used to stop life threatening hemorrhage – rather it illustrates a plethora of Boy Scout novelties of the tampon.
Elsewhere, there are anecdotes of tampons being used during World War I and II, but nothing specifically written from the era. Still, there is no definitive information that they were used as treatments for life-threatening wounds. In fact the majority of wounds for which tampons were used likely were NOT life threatening considering the person survived utilizing a device not intended to produce the necessary occluding effect of arterial bleeding. Kimberly-Clark, which produces Kotex® did make and provide Cellucotton, an absorbent wadding made of wood pulp as bandages. These are bandages, not tampons. It was after the war, when they began making sanitary napkins from this material. It was not till later, that tampons were made by Kimberly-Clark.[4] Another tampon story says nurses made their own tampons during World War I.[5] However, World War II, “production of cotton bandages and surgical dressings for the U.S. military now took place alongside the tampon assembly lines.”[4] Where the idea developed that these two devices that were made on the same assembly line meant they were interchangeable – we have no idea.
Massive bleeding from an artery in an extremity is a life-threating wound and also a preventable death.[6-9] This is a significant issue, not only for the US military, but also the citizens of our nation. Of the 147,000 trauma deaths in 2014, 20% or 30,000 were potentially survivable. Many of these were due to bleeding from an extremity.[6]
A tampon cannot provide the surface area or the pressure required to control massive bleeding. Tampons absorb blood, they do not provide any hemostatic assistance. The average tampon can absorb 9 mL of blood, or about two teaspoons. Life-threatening bleeding occurs when there is greater than 1500 mL creating a state of profound shock and impending multisystem organ failure.[10] It would be not only irresponsible, but down right ludicrous to think a tampon designed for 10 mLs of blood or even 10 times that at 100 mLs of blood would suffice to stop an arterial bleed capable of pumping out 1000 mLs in just over 3 minutes. A tourniquet or hemostatic dressing is preferred to control massive bleeding, regular gauze may be used, but it needs to be in sufficient amount. Based on square inches, a tampon can be as small as 4 square inches.
The American College of Surgeons and Stop the Bleed program recommends, when you do not have a hemostatic dressing, sterile dressings, or a tourniquet, use clothing to pack wound. This can be a shirt, pants, etc. even if your clothing is covered in body sweat, it’s more likely to provide more hemorrhage control than a tampon.
A search of peer-reviewed medical literature will fail to provide you with any data whatsoever on tampon use. This is likely, because no physician or researcher would recommend such a dangerous practice or suggest something so inferior to products that are battle tested with thousands of hours of research and hundreds of lives saved.
The authors have been tampoozled. It is clear, that the tampon argument is based off passed down and unverified anecdotes. It is dangerous and needs to be dismissed as a potential use for gunshot wounds. We need to stop having this conversation and stop spreading this old wives tale before someone dies as the result non-evidenced based medicine.
1. Control, I.o.M.D.o.H.S.P.I.o.M.D.o.H.P.D.P.I.o.M.C.o.T.S.S.C.f.D., Toxic Shock Syndrome: Assessment of Current Information and Future Research Needs : Report of a Study. 1982: National Academy Press.
2. Mikkelson, B. Tampon Wound Dressing: Tampon used to stanch deadly wound saves Marine's life? 2007 August 30, 2018]; Available from: https://www.snopes.com/fact-check/tampons-to-the-rescue/.
3. Creek. The Swiss Army Survival Tampon: 7 Survival Uses. 2014 August 30, 2018]; Available from: http://www.bioprepper.com/2014/01/19/the-swiss-army-survival-tampon-7-su....
4. History of Tampons and Tampax. 2018 August 30, 2018]; Available from: https://tampax.com/en-us/offers/tampax-history.
5. War Souvenirs. 2015 August 30, 2018]; Available from: http://www.period.media/factsfigures/war-souvenirs-2/.
6. National Academies of Sciences, E. and Medicine, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, ed. D. Berwick, A. Downey, and E. Cornett. 2016, Washington, DC: The National Academies Press. 530.
7. Tien, H.C., et al., Preventable deaths from hemorrhage at a level I Canadian trauma center. J Trauma, 2007. 62(1): p. 142-6.
8. Teixeira, P.G., et al., Preventable or potentially preventable mortality at a mature trauma center. J Trauma, 2007. 63(6): p. 1338-46; discussion 1346-7.
9. Eastridge, B.J., et al., Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma, 2012. 73(6, Supplement 5): p. S431-S437.
10. Rossaint, R., et al., The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care, 2016. 20: p. 100.
First off, thank you for taking the time to read and respond to our article. We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization.
We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.
We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper. Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requir...
First off, thank you for taking the time to read and respond to our article. We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization.
We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.
We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper. Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requiring invasive mechanical ventilation.
You are also correct in stating that excluding patients that were chronic tracheostomy and ventilator-dependent patients may affect the statistical analysis, but our present study was a retrospective analysis of a previously performed prospective interventional study which excluded these patients (1). Given the nature of the primary study, this data is unavailable. In spite of this limitation, we still feel that our study provides valuable data as it pertains to the outcomes of ED patients with respiratory failure requiring mechanical ventilation. Even with these patients excluded, the study cohort represents an extremely ill subset of patients with poor long-term outcomes; this is demonstrated by the fact that 42.8% of the original study population either died during their incident hospitalization or required hospital readmission within 30 days.
Lastly, we also agree that the level of dependency following hospitalization is extremely important to the patient and healthcare system. Unfortunately, this data was is not readily available to us and js also beyond the scope of our original study aims.
Once again, we thank you for taking the time to read our work and provide a thoughtful response to our article.
Cordially,
David B. Page & Brian M. Fuller
References:
1. Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Annals of emergency medicine. 2017;70(3):406-418.e404.
2. Fuller BM, Page D, Stephens RJ, et al. Pulmonary Mechanics and Mortality in Mechanically Ventilated Patients Without Acute Respiratory Distress Syndrome: A Cohort Study. Shock (Augusta, Ga). 2018;49(3):311-316.
3. Page D, Ablordeppey E, Wessman BT, et al. Emergency department hyperoxia is associated with increased mortality in mechanically ventilated patients: a cohort study. Critical care (London, England). 2018;22(1):9.
It is widely recognised that the management of patients with acute respiratory failure in the Emergency Department (ED) is a pivotal point that may influence outcomes at later stages in patient care pathways. In particular, the decision to submit patients to invasive mechanical ventilation (IMV) and the mode of ventilator settings utilised are of relevance in determining patient outcomes. It is also acknowledged that early hospital readmission following an episode of acute critical illness is a major problem not only for patients’ quality of life but also healthcare systems in general. Thus we read with great interest the recent retrospective study by Page DB et al., in which the authors investigated the relationship between ED pathways of care and the risk factors for unplanned 30-day readmissions. We applaud the authors on their efforts, however we also feel that there are several confounding issues that warrant further discussion.
Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, i...
It is widely recognised that the management of patients with acute respiratory failure in the Emergency Department (ED) is a pivotal point that may influence outcomes at later stages in patient care pathways. In particular, the decision to submit patients to invasive mechanical ventilation (IMV) and the mode of ventilator settings utilised are of relevance in determining patient outcomes. It is also acknowledged that early hospital readmission following an episode of acute critical illness is a major problem not only for patients’ quality of life but also healthcare systems in general. Thus we read with great interest the recent retrospective study by Page DB et al., in which the authors investigated the relationship between ED pathways of care and the risk factors for unplanned 30-day readmissions. We applaud the authors on their efforts, however we also feel that there are several confounding issues that warrant further discussion.
Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, including LOS and complications seen.
Secondly, with respect to the past medical history of patients included in the study it would be logical to expect that patients affected by chronic diseases (such as COPD, CHF and diabetes) are at greater risk of hospital readmission, especially those suffering from chronic pulmonary disorders. It is not clear from the discussion if this was indeed the case. It would also be of great interest to the reader to see statistical analysis of the impact of disease entities on LOS and readmission rates: for instance, do patients with CHF in acute cardiac pulmonary oedema require fewer days of IMV and as a consequence have a shorter LOS, whilst conversely standing a greater risk of readmission to hospital?
Thirdly, it is possible that the decision to exclude a number of patients with relevant medical conditions – including tracheostomy and long term ventilation patients, and those transferred from other hospitals) may affect the statistical analysis. Furthermore a significant percentage of patients requiring IMV are not defined as having critical conditions or disease processes, and are catergorised under “group other”. These patients contribute 19.5% of the readmission group compared to 25.1% in the not readmitted group. It is not clear from the authors’ comments the extent to which this high incidence of patients apparently unaffected by chronic illness may influence the findings of the study.
Finally, no information is provided by the authors regarding levels of dependency and the need for domicillary home assistance following hospital discharge. Patients who survive critical illness with significant care needs represent a significant challenge to healthcare systems worldwide, and some discussion of the role that individual organisations play in this issue would be interesting and enlightening.
We commend the authors on an interesting study which addresses some of the questions surrounding the impact that care provided acutely to patients may have on their longer term outcomes. We agree with the authors that further clinical trials need to investigate the questions that arise from this study and others like it.
Authors declare no conflict of interest
References
Angotti LB, Richards JB, Fisher DF, Sankoff JD, Seigel TA, Al Ashry HS, Wilcox SR. Duration of Mechanical Ventilation in the Emergency Department. West J Emerg Med. 2017 Aug;18(5):972-979. doi: 10.5811/westjem.2017.5.34099. Epub 2017 Jul 11. PubMed PMID: 28874952; PubMed Central PMCID: PMC5576636.
Page DB, Drewry AM, Ablordeppey E, Mohr NM, Kollef MH, Fuller BM. Thirty-day hospital readmissions among mechanically ventilated emergency department patients. Emerg Med J. 2018 Apr;35(4):252-256. doi: 10.1136/emermed-2017-206651. Epub 2018 Jan 5. PubMed PMID: 29305381.
Rezaee ME, Ward CE, Nuanez B, Rezaee DA, Ditkoff J, Halalau A. Examining 30-day COPD readmissions through the emergency department. Int J Chron Obstruct Pulmon Dis. 2017 Dec 27;13:109-120. doi: 10.2147/COPD.S147796. eCollection 2018. PubMed PMID: 29343950; PubMed Central PMCID: PMC5749550
We would like to thank Zhou and Wu for their thoughtful comments on our paper.
The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.
The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).
Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.
The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis...
We would like to thank Zhou and Wu for their thoughtful comments on our paper.
The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.
The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).
Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.
The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis diagnostic criteria. ICU admission would neither be appropriate or likely to change the prognosis of such patients. The IMPreSS study was primarily a study of ICU patients with sepsis (86% were admitted to ICU), thus by definition a different population to our study of ED all-comers who were universally screened for sepsis(1). A strength of our study is that, unlike much existing ICU-based sepsis research, it looks at this broader ED patient population. This also has relevance to the last issue raised, namely the suggestion that SOFA would be a fairer comparator. Calculating SOFA in the ED at initial assessement is generally not feasible and thus cannot realistically form the basis of initial clinical decisions. As the Sepsis 3 authors note, “the SOFA score is not intended to be used as a tool for patient management”(2), thus qSOFA was created as a prognostic tool which could be used in settings such as the ED. This was therefore the appropriate comparator to use in our study.
References
1. Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med 2015;41(9):1620–8.
2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315(8):801–10.
Dear Sirs
We read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category se...
Dear Sirs
We read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category set at 240 minutes. The South African Triage Scale is therefore another available option as we continuously strive to improve the quality of care and patient experience in our healthcare systems.
References
1. Dalwai M, Tayler-Smith K, Twomey M, et al Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan Emerg Med J Published Online First: 16 March 2018. doi: 10.1136/emermed-2017-207062
2. Shalini Pooransingh, L. K. Teja Boppana, and Isaac Dialsingh, “An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country,” Emergency Medicine International, vol. 2018, Article ID 6821323, 5 pages, 2018. https://doi.org/10.1155/2018/6821323.
Dear Authors,
Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,
We do not disagree with the comment, hence our conclusion that, “CT is a valid first line imaging technique in suspected occult hip fracture and is easily accessible in most centres.” The intention of the BET was to present evidence on whether one modality was better than the other and so we looked for studies comparing the two imaging techniques. The study by Thomas et al. forms part of the evidence that CT scanning is a valid method of detecting occult hip fractures and so was not included in the table of evidence.
Thomas RW, Williams HLM, Carpenter EC, Lyons K. The validity of investigating occult hip fractures using multidetector CT. Br J Radiol
I read this article with interest as I am currently launching a QUIP on this exact subject.
As a declaration of possible bias I am looking to use highly sensitive CTs to screen off negative findings to frailty services and thus avoiding orthopaedic beds.
I am surprised that more credence was not given to the study by Thomas et al. who's sensitivity and specificity was 100% for ct. The study is one that clearly identifies MDCT as the protocol of choice when identifying occult hip fractures. I am not sure whether this is directly comparable to other studies in this way, and therefore some doubt exists as to whether current discrepancies in reporting are more attributable to the scanning protocol used.
I feel that the current nice guidelines are out of date with modern CT scanning and is having undue influence on first line diagnostics of occult hip fractures.
I do appreciate the move forward for CT scanning hips as first line diagnostics thus cutting bed-days/patient, expediting correct treatment and improving patient experience.
The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
Show MoreReferences
(1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
Blood pressure measurement in the Post-SPRINT Era
Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
(2)Giles TD., Egan P
Inter-arm differences in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Giles TD., Egan P
Inter-arm dif...
We read with interest the recent article by Setala et al, where active compression decompression cardiopulmonary resuscitation (ACD-CPR) was compared with manual CPR. 1 In this study, to ensure continuous high-quality resuscitation, an audiovisual feedback defibrillator (Zoll X Series, Real CPR Help, ZOLL Medical Corporation, USA) was used. This is a key element for cardiac arrest studies. It is known that quality of CPR is an important modifier in cardiac arrest studies. 2 High-quality CPR is necessary to be able to compare and generalize the results. There is, however, a major methodologic flaw in the Setala et al study. None of the accelerometers used in feedback defibrillator are adapted to analyze ACD-CPR. The issue arises from the fact that the accelerometers are designed to measure only one distance from the chest resting point at the end of the passive decompression to the compression maximum depth. In the Setala et al study, there was no difference in distance between groups 76 (SD 1.3) mm versus 71 (SD1.0) mm. However, in ACD CPR, you need active compression (5 cm) combined with active decompression (3 cm or 15kg of pulling). Given the reported data, there are two distinct possibilities. The first is that Setala et al were able to perform active decompression (rising the chest higher than the chest resting point) but that their compressions were not adequately deep enough. As a result, ETCO2 would be lower compared to CPR with high-quality compression. The second...
Show MoreWe applaud the authors for their effort to educate the bystander and even medical professionals with a means to provide care for the injured in terrorist attacks. While the majority of the information provided is based in historical evidence, in today’s era of superior wound packing materials the use of tampons for gunshot wounds (GSWs) is an inferior and dangerous suggestion.
Tampons have been around for many thousands of years for vaginal bleeding, but nothing has been documented for their use in GSWs.[1] Stories of tampon use have been around since the Vietnam era. There have even been anecdotes posted on Snopes.com from the war in Iraq.[2] The story is full of unsubstantiated information, yet it is a common reference for many.
One can find in the fringe of the Internet, other claims of tampon effectiveness. Bioprepper claims tampons are “designed to be ultra-absorbent” and “can be used to plug a bullet hole until…accounts of this use date back to World War I.”[3] They go on to say, “Many items in modern society were first developed as a facet of military research – tampons being a prime example.” This is absolutely false. Not only that the article itself never demonstrates a tampon being used to stop life threatening hemorrhage – rather it illustrates a plethora of Boy Scout novelties of the tampon.
Elsewhere, there are anecdotes of tampons being used during World War I and II, but nothing specifically written from the era. Still, there is no def...
Show MoreDr. Purro,
First off, thank you for taking the time to read and respond to our article. We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization.
We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.
We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper. Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requir...
Show MoreDear Editor,
It is widely recognised that the management of patients with acute respiratory failure in the Emergency Department (ED) is a pivotal point that may influence outcomes at later stages in patient care pathways. In particular, the decision to submit patients to invasive mechanical ventilation (IMV) and the mode of ventilator settings utilised are of relevance in determining patient outcomes. It is also acknowledged that early hospital readmission following an episode of acute critical illness is a major problem not only for patients’ quality of life but also healthcare systems in general. Thus we read with great interest the recent retrospective study by Page DB et al., in which the authors investigated the relationship between ED pathways of care and the risk factors for unplanned 30-day readmissions. We applaud the authors on their efforts, however we also feel that there are several confounding issues that warrant further discussion.
Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, i...
Show MoreWe would like to thank Zhou and Wu for their thoughtful comments on our paper.
The discrepancy in Table 1 between the first and second to last row is due to an error. The first row should note ‘Admitted to ICU (n=53)’.
The NEWS, SIRS, and qSOFA scores were directly recorded in the patient electronic medical record (EMR), and our initial step was to extract these scores from the EMR. When these values were missing, the individual components of the scores were extracted from paper records, and the scores calculated. The high number of missing values of the qSOFA were due to the fact that it was not routinely recorded until part way through the study period. The fact that 6% of subjects still had missing values after manual chart review resulted from one or more of the components of any of the three scores not being recorded (or the record being missing) when the patient initially presented to the emergency department (ED).
Regarding the time window, the qSOFA, NEWS, and SIRS scores used in our analysis were all based on their initial values when the patient was assessed, which would typically be within minutes of ED arrival. This therefore reflects the values upon which clinicians initially treating the patients would base their decisions.
The high proportion of patients who died that were not admitted to ICU reflects the fact that many patients with advanced age and co-morbidities ultimately die from infection, which at some stage may meet sepsis...
Show MoreDear Sirs
Show MoreWe read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category se...
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