ED Department Research Articles

BHSeP35 Incidence and outcome of emergency presentation with complicated abdominal wall hernias: a retrospective study of 10 years in a District General Hospital

Abstract Abdominal wall hernias including groin defects are a common surgical encounter in outpatient clinic , however there is an increasing number of emergency presentations with same problem to ED department seen in recent years. It is known that best outcome on surgical pathologies is obtained when patient is operated on elective basis, with all necessary pre-optimization done before surgery . It is even more important to achieve pre-optimization steps when abdominal wall defects are repaired surgically, in order to obtain best possible outcomes. Starting from this postulate, the authors of the study wanted to look at the outcomes of patients operated with any type of abdominal wall hernia in our hospital , who had an emergency presentation, over the last 10 years (2014–2023). It is of common practice currently in UK to avoid mesh implantation when repairing a complicated hernia on emergency basis, particularly if any bowel involvement. At the same time, the current EHS guidelines advise using a prosthetic reinforcement on all ventral hernias over 1 cm diameter and in all groin hernias, in order to prevent recurrence. Our retrospective audit looked at several parameters on all presentations with emergency hernias, as follows: immediate surgery vs delayed to elective list, open vs MIS approach, LOS, mesh vs primary stitch repair, long term outcome at follow-up including recurrence, chronic pain and other specific hernia complications.

Abstract WP17: Best Practices for Optimizing Door-to-Needle Times: Road to Target Stroke Phase III

Introduction: The launch of AHA’s Target: Stroke Phase III in 2019 challenged stroke centers to achieve DTN times ≤ 30 min of arrival to ≥ 50% of AIS patients treated with IV thrombolytics. At the time of Phase III launch, we were achieving the DTN ≤ 30 min goal in 43% of patients (median DTN 34 min) at our CSC (> 1300 ischemic stroke discharges/year). Methods: Our stroke team, in collaboration with the ED and other relevant departments, analyzed the stroke alert process and implemented incremental changes (listed below, 1 change per month to allow focus) to improve DTN times. • Vascular neurologist (VN) arriving to ED before EMS for pre-hospital stroke alerts • Assigning specific roles to each stroke team member • Calling out time since arrival every 5 minutes • Minimizing time in ED prior to CT (ie, not changing patient into gown, bypassing EKG) • Premixing alteplase (prior to TNK transition) • Giving IV thrombolytic in CT prior to CTA • Implementing video stroke alerts to allow VN to have virtual presence 24/7 DTN times were collected at launch of Phase III in 2019, and after changes were implemented. Objectives were to improve DTN times from baseline, in order to optimize care and achieve Phase III goals. Results: DTN times improved from a median of 34 min in FY19 to 25 min in FY21, corresponding to an increase in achievement of the Target: Stroke Phase III goal from 43% to 95% (Figure 1). Conclusion: By implementing collaborative and focused interventions, our CSC was able to improve and optimize the workflow of stroke patients receiving IV thrombolytics, allowing us to achieve the rigorous Target: Stroke Phase III goals and optimize patient outcomes.

The Role of Nurses as Alternative Providers of Medical Services in Community-Based Care

The demands on the Irish acute and community-based health services are exponential, increasing the patient flow to the GP practice and/or ED department. Many of the attendances at both are as a result of a deficit in alternative options for the population to attend or because the GP practice and ED department have no alternatives to offer patients. This is also due to the increased acuity and complexity of patients being cared for. This is further compounded by a reduction in the workforce further affecting scheduled care. The nursing workforce has experienced significant impact as a result of the pandemic with many nurses deciding to not remain in the profession and instead reskilling for other professions outside of nursing. Other nurses travel for work abroad for experiences not acquired during the pandemic. Those nurses that have remained in the profession are now retiring and some choosing to do so earlier and returning to work through agencies and other alternatives in a flexible way to acquire a work/life balance. The health systems are increasing work pressures on nurses that lead to increased risk of patient and professional risk that many nurses are not comfortable with. Together these issues are compounded onto an existing health structure that is unable to manage the escalation in population needs, year on year.
 Sláintecare is the current Irish health policy with principles including hospital avoidance and early discharge including patient satisfaction, choice and flow. Nursing policy advocates for the advanced capability and competency from graduate to advanced practice. Whilst much attention is duly associated with advanced practice, the practice of all nurses to the full scope of practice is also advocated. Whilst not funded in the same way as advanced practice, opportunities are available for the profession to develop there mode of service delivery similar to other professionals such as GPs, Dentists, Opticians and Pharmacists. The HSE policy advocates for the contracting of all types of services to meet the healthcare demands, however nurses are normally employed within a public/private service or within agency employment.
 This proposed initiative is the development of a private clinical nursing service that can be delivered in the home to meet the patients’ needs avoiding attendance at the hospital and GP clinic. It differs to the current community nursing service in that it offers universal health coverage. Currently, there is no opportunity for public funding to support reimbursement. As mentioned earlier the PCRS system does not reimburse nurses for clinical work undertaken privately and is an issue that requires further investigation. The cost of this project already demonstrates exponential savings to the health services. It is also attractive to the workforce and offers a quality of life to the patients treated in their own homes.. What is offered is the opportunity for each nurse, who wishes to work independently, to place a plaque on the wall and ‘open for business’. This mode of service delivery is novel, innovative and is an opportunity to discover new ways of practice for nurses

Inappropriate CT examinations: how much, who and where? Insights from a clinical decision support system (CDSS) analysis.

To assess the appropriateness of Computed Tomography (CT) examinations, using the ESR-iGuide. A retrospective study was conducted in 2022 in a medium-sized acute care teaching hospital. A total of 278 consecutive cases of CT referral were included. For each imaging referral, the ESR-iGuide provided an appropriateness score using a scale of 1-9 and the Relative Radiation Level using a scale of 0-5. These were then compared with the appropriateness score and the radiation level of the recommended ESR-iGuide exam. Pearson's chi-square test or Fisher exact test was used to explore the correlation between ESR-iGuide appropriateness level and physician, patients, and shift characteristics. A stepwise logistic regression model was used to capture the contribution of each of these factors. Most of exams performed were CT head (63.67%) or CT abdominal pelvis (23.74%). Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." The mean radiation level for actual exam was 3.2 ± 0.45 compared with 2.16 ± 1.56 for the recommended exam. When using a stepwise logistic regression for modeling the probability of non-appropriate score, both physician specialty and status were significant (p = 0.0011, p = 0.0192 respectively). Non-surgical and specialist physicians were more likely to order inappropriate exams than surgical physicians. ESR-iGuide software indicates a substantial rate of inappropriate exams of CT head and CT abdominal-pelvis and unnecessary radiation exposure mainly in the ED department. Inappropriate exams were found to be related to physicians' specialty and seniority. These findings underscore the urgent need for improved imaging referral practices to ensure appropriate healthcare delivery and effective resource management. Additionally, they highlight the potential benefits and necessity of integrating CDSS as a standard medical practice. By implementing CDSS, healthcare providers can make more informed decisions, leading to enhanced patient care, optimized resource allocation, and improved overall healthcare outcomes. • The overall mean of appropriateness for the actual exam according to the ESR-iGuide was 6.62 ± 2.69 on a scale of 0-9. • Seventy percent of the actual imaging referrals resulted in an ESR-iGuide score corresponding to "usually appropriate." • Inappropriate examination is related to both the specialty of the physician who requested the exam and the seniority status of the physician.

Linking emergency care and police department data to strengthen timely information on violence-related paediatric injuries

BackgroundCombined ED and police department (PD) data have improved violence surveillance in the UK, enabling significantly improved prevention. We sought to determine if the addition of emergency medical service (EMS)...

Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial

BackgroundAnxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life. ObjectivesThe Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities. MethodsThe PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups. DiscussionPACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

Effectiveness of a targeted telephone-based case management service on activity in an Emergency Department in the UK: a pragmatic difference-in-differences evaluation

BackgroundThis study evaluates the effectiveness of a targeted telephone-based case management service that aimed to reduce ED attendance amongst frequent attenders, known to disproportionately contribute to demand. Evidence on the effectiveness of these services varies.MethodsA 24-month controlled before-and-after study, following 808 patients (128 cases and 680 controls (41 were non-compliant)) who were offered the service in the first four months of operation within a UK ED department. Patients stratified as high-risk of reattending ED within 6 months by a predictive model were manually screened. Those positively reviewed were offered a non-clinical, nurse-led, telephone-based health coaching, consisting of care planning, coordination and goal setting for up to 9 months. Service effectiveness was estimated using a difference-in-differences (DiD) analysis. Incident rate of ED and Minor Injury Unit (MIU) attendances and average length of stay in intervention recipients and controls over 12 months after receiving their service offer following ED attendance were compared, adjusting for the prior 12-month period, sex and age, to give an incidence rate ratio (IRR).ResultsIntervention recipients were more likely to be female (63.3% versus 55.4%), younger (mean of 69 years versus 76 years), and have higher levels of ED activity (except for MIU) than controls. Mean rates fell between periods for all outcomes (except for MIU attendance). The Intention-to-Treat analysis indicated non-statistically significant effect of the intervention in reducing all outcomes, except for MIU attendances, with IRRs: ED attendances, 0.856 (95% CI: 0.631, 1.160); ED admissions, 0.871 (95% CI: 0.628, 1.208); length of stay for emergency and elective admissions: 0.844 (95% CI: 0.619, 1.151) and 0.781 (95% CI: 0.420, 1.454). MIU attendance increased with an IRR: 2.638 (95% CI: 1.041, 6.680).ConclusionsTelephone-based health coaching appears to be effective in reducing ED attendances and admissions, with shorter lengths of stay, in intervention recipients over controls. Future studies need to capture outcomes beyond acute activity, and better understand how services like this provide added value.

EP-570 Rare case of pre-pyloric perforation of stomach secondary to foreign body ingestion

Abstract Background Gastrointestinal perforation remains a common cause of acute abdomen in clinical practice. However, pre-pyloric perforation secondary to ingested foreign body (FB) in the adult population is rare. Nearly 80–90% of ingested foreign bodies will pass through the GI system spontaneously with only 1% requiring surgery. We report a rare incidence of pre-pyloric perforation in a patient unaware of ingestion of any foreign body. Case presentation A 59 year old female with no medical history, presented to the ED department with severe epigastric pain, vomiting and fever. She had a peritonitic abdomen and corroborative inflammatory markers. An urgent computed tomography scan demonstrated a 7×5cm collection near the transverse colon and a linear streak of hyperdense material near the collection. Patient had no recollection of ingestion of FB. Diagnostic laparoscopy followed by laparotomy, revealed inflammation and necrotic adipose tissue between the transverse colon and stomach walling of a purulent cavity. A 2cm shard of glass was retrieved. Examination of the posterior wall of the stomach eventually located the site of perforation. Generous washout, debridement and suture repair with omental plug was performed. She made an uneventful recovery. Conclusion Sharp objects do not pass via the pylorus easily and can cause perforation in the proximal part of gastrointestinal tract. Any features of complication mandates exploration and examination of the posterior surface of the stomach is quintessential

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday and into nights and weekends. This is especially true for those who work in campus safety.

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Ed Department suspends seizure of refunds for loans Charitable giving up for HBCUs, community colleges College offers $10,000 reward for arrest of vandal Vice President resigns after prostitution solicitation arrest COVID‐19 adversely affected adjuncts’ working conditions

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday and into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Take steps to prevent violations and lawsuits related to wage‐and‐hour requirements

One common thread that runs through almost every higher ed department is that the entire operation requires long and irregular hours, extending from the traditional workday and into nights and weekends. The collective commitment of all employees to do their respective part enables each department to accomplish its varied missions. This approach is often demonstrated by the willingness of dedicated employees to work long hours well in excess of 40 hours per week. Although that commitment of extra time and effort is acceptable for many employees within the department who are considered exempt from wage‐related overtime payment obligations, higher ed administrators must tread carefully regarding expecting any additional time or effort from nonexempt hourly staff. One university recently learned this lesson the hard way.

Adequacy of Clinical Information on Trauma CT Requests From ED Department

There is evidence to suggest a correlation between inadequate clinical information and inaccurate radiology reports. Additionally, multiple research studies confirm the overuse of imaging in ED, particularly in the older group of patients. Unjustified CT Trauma requests not only affect the report to be produced, but also can delay appropriate management.

A Bird’s Eye View on Firearm Injuries Lady Reading Hospital MTI, Peshawar

Background There is a concern that firearm injuries are very common reported at lady Reading hospital Peshawar MTI, but the there are no contemporary studies. Gunshot wound are persistent burden on community as well as on hospitals Aim: To evaluate trends of firearm injuries reporting to LRH their anatomical distributions and their outcomes. Methods: This prospective randomized study (a pilot project for public health alert) was conducted in Accident & Emergency Department of Lady Reading hospital MTI, Peshawar KPK, from 1st May, 2020 to 1st October, 2020. Hundred patients with firearm injuries to different region shot were included in this study. Data collected on predesigned proforma and entries in HMIS used after stabilizing the patient. A prospective pilot study done over a period of six months from 1st May, 2020 to 1st October, 2020 in trauma section of Accident Emergency department of Lady Reading hospital MTI Peshawar. Results: Patients of all age groups with firearm injuries were included in this study from May 2020 to October 2020. Data was collected on predesigned proforma as well as HMIS (health management information system) of ED department. A total of 100 patients presented to LRH with firearm injuries during six months. Males outnumbered female by 6:1 accounting for 100(85%) of injured. : Domestic violence was found to be the most common reason for the firearm use 44(44%), Don’t know or refuse to share was 29(29%), rivalry 12(12%), land and property conflict 9(9%), street fight 3(3%) accidental gunshots 2%, (n=25) and robbery 1.1% (n=1).The most common firearm used for inflicting injury was pistol (70%), shot gun (2.2%), curiously 16% were either reluctant or were never knowing about the weapon Conclusion: Firearm injuries are common public health problem globally, in our set up situation is more grievous and less highlighted, the most common cause being domestic violence, lack of education, easy availability of arms, illegal or legal weapon ownership making situation worst in the form of premature deaths and disability. Understanding the nature of problem can prevent this violence Keywords: Firearms, violence, gunshot wounds, homicides, suicides

Сравнительный анализ результатов измерения артериального давления автоматическими тонометрами у пациентов с фибрилляцией предсердий

Aim: to specify indications for use of distinct types of blood pressure monitors (mechanical, automatic with arrhythmia detector and upper arm cuff, and automatic with arrhythmia detector and wrist cuff) in patients with atrial fibrillation (AFib). Patients and Methods: 202 patients (mean age 61.8 ± 1.3 years) with paroxysmal AFib of any origin occurred no more than 1 month ago and atrial tachysystole were enrolled. All patients had a history of hypertension of various severity. This study was conducted in three units, i.e., ICU, ED, and therapeutic department. Blood pressure (BP) measurements were performed at 8 a.m., 12 p.m., and 4 p.m. using various types of BP monitors in turn, i.e., mechanical BP monitor (whose readings were considered reference values), automatic BP monitor OMRON M2 BASIC HEM-7121-ALRU (OMRON M2 BASIC) with upper arm cuff, automatic BP monitor OMRON RS2 HEM-6121-Ru (OMRON RS2) with wrist cuff, and automatic BP monitors of other manufacturers with upper arm cuff (B1 and A1) or wrist cuff (B2 and A2). Results: in patients with AFib of any severity, BP readings measured by automatic BP monitors OMRON M2 BASIC and OMRON RS2 demonstrate no significant differences compared to BP readings measured by mechanical BP monitor. Meanwhile, BP readings measured by BP monitors of other manufacturers (A1, A2, B1, and B2) were significantly different from reference values. The more severe was arrhythmia, the more significant the differences were. Conclusions: automatic BP monitors OMRON M2 BASIC and OMRON RS2 that provide as accurate as possible BP readings can be recommended for measuring BP in patients with AFib of any severity in ED, outpatient wards, and at home (self-control). KEYWORDS: hypertension, atrial fibrillation, blood pressure measurement, blood pressure variability, blood pressure monitor. FOR CITATION: Vertkin A.L., Sycheva A.S., Kebina A.L. et al. Measurement of blood pressure using automatic monitors in patients with atrial fibrillation: a comparative analysis. Russian Medical Inquiry. 2021;5(4):189–195 (in Russ.). DOI: 10.32364/2587-6821-2021-5-4-189-195.