Emergency Attendances Research Articles

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients.

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED)using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Mental health emergency admissions in the paediatric emergency department.

To evaluate the demographic characteristics, diagnoses and length of stay of mental health emergency attendance to the paediatric emergency department (ED), to determine the burdens these patients brought to the paediatric ED and to the national economy by examining hospital costs. This retrospective observational study was conducted in a tertiary hospital's paediatric ED in Turkey. Data were obtained from the electronic medical record system from January 2018 to January 2020. A total of 142 admissions were included of whom 60% were female. The mean age was 15.2 ± 1.8 years, 50% of cases were suicide attempts and 19% were alcohol intoxications. The majority (85.9%) of patients were discharged from the emergency observation unit. Among the diagnostic groups, the mean age was higher in patients with a history of substance abuse. There was a female predominance among patients who were admitted due to suicide attempts. Among the diagnostic groups, the duration of hospital stay and cost of hospitalization were higher in patients who were followed up with a diagnosis of suicide attempt. Mental health problems are frequent in the paediatric ED. We determined that the most common cause of attendance in paediatric emergencies was suicide attempts, and the length of hospital stay and hospital cost were higher in this diagnostic group. Although further research is necessary to determine national trends in paediatric mental health problems in the paediatric ED, screening strategies and early detection and interventions in primary healthcare may allow more effective care for childhood mental health problems.

Long-term Real-world Protection Afforded by Third mRNA Doses Against Symptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infections, Coronavirus Disease 19-related Emergency Attendances and Hospitalizations Amongst Older Singaporeans During an Omicron XBB Wave.

Literature on long-term real-world vaccine effectiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) booster vaccines (up to and beyond 360 days) is scarce. We report estimates of protection against symptomatic infection, emergency department (ED) attendances and hospitalizations up to and beyond 360 days post-receipt of booster messenger RNA (mRNA) vaccines among Singaporeans aged ≥60 years during an Omicron XBB wave. We conducted a population-based cohort study including all Singaporeans aged ≥60 years with no documented prior SARS-CoV-2 infection who had previously received ≥3 doses of mRNA vaccines (BNT162b2/mRNA-1273), over a 4-month period during transmission of Omicron XBB. We reported the adjusted incidence-rate-ratio (IRR) for symptomatic infections, ED attendances and hospitalizations at different time-intervals from both first and second boosters, using Poisson regression; with the reference group being those who received their first booster 90 to 179 days prior. In total, 506 856 boosted adults were included, contributing 55 846 165 person-days of observation. Protection against symptomatic infections among those who received a third vaccine dose (first booster) waned after 180 days with increasing adjusted IRRs; however, protection against ED attendances and hospitalizations held up, with comparable adjusted IRRs with increasing time from third vaccine doses (≥360 days from third dose: adjusted IRR [ED attendances] = 0.73, 95% confidence interval [CI] = .62-.85; adjusted IRR [hospitalization] = 0.58, 95% CI = .49-.70). Our results highlight the benefit of a booster dose in reducing ED attendances and hospitalizations amongst older adults aged ≥60 years with no documented prior SARS-CoV-2 infection, during an Omicron XBB wave; up to and beyond 360 days post-booster. A second booster provided further reduction.

Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents.

Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.

Comparing Direct and Video Laryngoscopy Skills Between Resident and Attending Emergency Physicians.

Introduction Advances in airway technology, in particular video laryngoscopy, are forcing attending emergency medicine physicians to master and maintain innovative airway skills. This study compares intubation times and other airway outcomes between resident and attending physicians using direct and video laryngoscopy in a mannequin model. Methods Fifty emergency medicine resident and attending physicians were asked to intubate a mannequin, using direct laryngoscopy, a C-MAC standard geometry blade, and a GlideScope hyperangulated blade. Intubation times, intubation success and accuracy, Cormack-Lehane grades, and the physician's opinion of the ease of the intubation were recorded for each intubation. Results Second-year residents had significantly quicker intubation times than attending physicians with all 3 intubation modalities. They also outperformed the interns when using the C-MAC standard geometry blade and had faster intubation times compared to third-year residents using direct laryngoscopy. When using the GlideScope hyperangulated blade, all 3 years of residents had lower intubation times compared to attending physicians and they were more accurate with endotracheal tube placement. Unlike the second-year residents, the third-year residents were not faster at direct laryngoscopy compared to the attending physicians. Conclusion Second-year residents outperformed their resident counterparts and the attending physicians with improved intubation times. Nontraditional intubation techniques associated with the GlideScope hyperangulated blade must be learned, practiced, and maintained by attending physicians, which is reflected in their longer intubation times compared to the residents. In addition, DL skills can deteriorate among resident physicians if they are not used on a regular basis.

P-001 RISK FACTORS, HEALTHCARE RESOURCE USE AND COSTS ASSOCIATED WITH INCISIONAL HERNIA REPAIR IN ENGLAND USING HOSPITAL EPISODE STATISTICS

Abstract Aim To evaluate the burden of incisional hernia (IH) to patients and healthcare services in England. Material & Methods We conducted a retrospective observational study in Hospital Episode Statistics including adult patients who underwent stoma, transplant, or aortic surgery (index) between 01/04/2017 and 31/03/2022. We followed patients for development of incisional (including parastomal) hernia necessitating repair within 2 years post-index operation, describing patients by surgery type, number of comorbidities (prior abdominal surgery, chronic lung disease, diabetes, immunosuppressed status, obesity, smoker), and financial year. We evaluated costs associated with inpatient, outpatient, and Accident & Emergency attendances within 2 years post-index operation using National Health Service reference costs. Results Of 430,339 patients (132,584 stoma, 3,247 transplant, 294,508 aortic surgery), 24,949 developed IH requiring repair (6.74% overall, 13.74% stoma, 5.51% transplant, 2.80% aortic surgery). Operative IH was observed in 11.46%, 5.54%, and 1.94%, for patients with 0–2 comorbidities following stoma, transplant, and aortic surgery, respectively; for patients with 5–6 comorbidities, 29.70%, 5.97%, and 6.91% underwent repair of IH. For all years, costs were higher for patients with IH versus those without IH. Costs varied by surgery type and number of comorbidities and were driven by non-elective admissions. The difference in mean total costs for IH versus non-IH following surgery performed in 2017 was £16,350 for stoma, £19,268 for transplant, and £54,518 for aortic surgery. Conclusions Rates of IH repair increase alongside the number of comorbidities. A large number of patients require IH repair within 2 years of surgery, increasing the cost of care.

Diabetes Management and Outcomes among Patients with Type 2 Diabetes Attending a Renal Service.

Patients with comorbid type 2 diabetes mellitus (T2DM) and renal disease, particularly those treated with insulin, often require complex pharmacological treatment and management of other diabetes complications. To assess the achievement of metabolic targets and compare the current management of renal service attenders with insulin- and noninsulin-treated T2DM. Single-centre retrospective cross-sectional study involving medical record review of patients with T2DM aged ≥18 years who visited a metropolitan renal outpatient clinic in 2017. Univariable analysis and multivariable logistic regression were used to identify factors associated with insulin treatment. Among 268 patients (45.5% insulin-treated), mean HbA1c was higher in insulin-treated vs. noninsulin-treated patients (8.0 ± 1.8% (64 mmol/mol) vs. 6.8 ± 1.2% (51 mmol/mol), p < 0.001). Significantly fewer insulin-treated patients had HbA1c ≤ 7.0% (53 mmol/mol; 31.8% vs. 69.3%, p < 0.001). More insulin-treated patients had ischaemic heart disease (46.7% vs. 33.6%, p = 0.028), diabetic foot disease (15.6% vs. 4.8%, p = 0.003), retinopathy (40.2% vs. 11.0%, p < 0.001), and emergency attendance for severe hypoglycaemia (3.8% vs. 0% p = 0.042). Insulin treatment was more associated with chronic kidney disease stages 4-5 (adjusted odds ratio (aOR) 2.41, 95% CI 1.07-5.43), retinopathy (aOR 3.10, 95% CI 1.04-9.27), and podiatry review (aOR 5.06, 95% CI 1.20-21.38). Only 38 (14.2%) individuals were seen by a colocated public multidisciplinary diabetes service in 2017. Renal clinic attenders with T2DM, particularly if insulin-treated, remained at increased risk of diabetes-related complications, including severe hypoglycaemia, with limited input from the colocated hospital diabetes team. Approaches to increase coordination of diabetes care among renal patients should be investigated.

OA43 Peri-procedural management and incidence of bleeding events following musculoskeletal injections and aspirations in people on anticoagulation and antiplatelet therapy

Abstract Background/Aims Corticosteroid injections and aspirations are common interventions for managing musculoskeletal conditions and inflammatory arthritis. However, there remains limited safety evidence to support safe practice for injection decisions in people on anticoagulant therapy, particularly direct oral anticoagulant (DOAC) medications regarding incidence of bleeding events or complications. Although there is increasing evidence for warfarin continuation, there is considerable variation in published guidance, manufacturer recommendations and specialty approaches to peri-procedural management of DOACs. This study reports on peri-procedural practice regarding continuation or discontinuation, bleeding events and complication rates in people on anticoagulant and antiplatelet medication undergoing musculoskeletal injections. Methods A prospective observational study was undertaken (October 2018- December 2020) using weekly electronic database searches to identify musculoskeletal injection and aspiration procedures undertaken in orthopaedics, rheumatology and radiology in two large NHS providers. Reply-paid questionnaires were sent to all consecutive adults within two weeks of procedures. Information was collected on bleeding events/complications, anticoagulant/antiplatelet use, products, doses, indications, INR levels and checking, discontinuation/re-initiation, comorbidities, and other medications. Concurrent electronic searches were also undertaken for emergency attendance or admissions within 30 days following procedures to identify unreported serious bleeding events or complications. Results Electronic searching identified 5,080 musculoskeletal procedures with 1,338 (26.3%) respondents (ages 20-99 years) returning questionnaires. 356 received &amp;gt;1 procedure over the timeframe and 49 bilateral procedures. There were 45 reports of bleeding events and all non-clinically significant localised bruising of the skin: 25/1106 (0.2%) without anticoagulation or antiplatelet therapy; 20/232 (8.6%) with anticoagulant/antiplatelet therapy, occurring only with continued medications. Incidences included: warfarin with unknown INR levels (n= 2/36, 5.5%); DOACs (n=9/72, 12.5%) [apixaban (5/24, 21%), rivaroxaban (4/45, 8.8%)]; antiplatelets [clopidogrel (4/28, 14.2%), clopidogrel &amp; NSAID (1/4, 25%), aspirin (1/72, 1.3%), aspirin &amp; NSAID (2/11, 18.1%), NSAID (1/3, 33.3%)]. Localised bruising was more common with DOAC continuation, aspirin with NSAID use, clopidogrel use and older age. Only 3/72 respondents on DOACs reported instructions to interrupt medications (orthopaedics). There were no serious bleeding or thromboembolic events identified through electronic searches for any recipient within 30 days following procedures. Conclusion This observational study found no significant bleeding events resulting from musculoskeletal injections or aspirations with continuation of warfarin (INR &amp;lt; 3.80), direct oral anticoagulant use, antiplatelet or combination therapy. The only consequence reported was some occurrence of localised bruising, also reported without medication use. It was not universal practice to determine INR levels prior to procedures with warfarin use and common practice to continue DOACs and antiplatelet medications. This research adds to evidence that musculoskeletal injections and aspirations appear to be very low risk procedures for bleeding complications with continuation of anticoagulant and antiplatelet therapy. Further research on intra-articular or intra-tissue iatrogenic consequences with anticoagulant/antiplatelet use is needed to add to procedural risk/benefit evaluations. Disclosure C. McCrum: Grants/research support; Funding grant to provide professional education workshops-Novartis, Janssen. S. Grainger: None.

FOCUS may detect wall motion abnormalities in patients with ACS

BackgroundChest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department. PurposeWe sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients. MethodsWe performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training. ResultsFOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82–98), specificity 35% (95% CI, 15–61), and overall accuracy of 78% (95% CI, 66–87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64–96), a specificity of 56% (95% CI, 23–85%), and an accuracy of 77 (95% CI, 58–90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64–95%), a specificity of 75% (95% CI, 36–96%), and an accuracy of 82% (95% CI, 65–93%). ConclusionsOur retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.

Evaluation of the Educational Value of Low-Cost Training Model for Emergency Cricothyrotomy.

In this study, we aimed to evaluate the educational value and students' satisfaction with the hand-made low-cost cricothyrotomy simulation model. A low-cost and hand-made model and a high-fidelity model were used to assess the students. The students' knowledge and satisfaction were evaluated using a 10-item checklist and a satisfaction questionnaire, respectively. Medical interns in the present study participated in a two-hour briefing and debriefing session held in the Clinical Skills Training Center by an emergency attending doctor. Based on the results of data analysis, no significant differences were found between the two groups in terms of gender, age, the month of internship, and last semester's grade (P = .628, .356, .847, and .421, respectively). We also found no significant differences between our groups in terms of the median score of each item in the assessment checklist (P = .838, .736, .805, .172, .439, .823, .243, .950, .812, and .756, respectively). The study groups had no significant difference in the median total scores of the checklist as well (P = .504). Regarding the students' satisfaction, our results showed that interns evaluated their experience of the model as positive (median scores of 4 and 5 out of 5). They also gave the hand-made model a median score of 7 in comparison with the high-fidelity model and 8 out of 10 for its usability. The study results showed that a low-cost model could be as effective as an expensive high-fidelity model for teaching the necessary knowledge of cricothyrotomy techniques to medical trainees.

The evolution of diagnosis from symptom onset to death in progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) compared to Parkinson’s disease (PD)

BackgroundMisdiagnosis and delayed diagnosis in progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) are common. Few studies have systematically evaluated the diagnostic process from symptom onset to death in representative cohorts.MethodsAll PSP/CBD cases (n = 28/2) and age-sex matched Parkinson’s disease (PD) cases (n = 30) were identified from a UK prospective incident Parkinsonism cohort. Medical and research records were reviewed to compare median times from first index symptom to key diagnostic milestones and the nature/timing of secondary care referral and review.ResultsIndex symptoms were similar apart from more tremor in PD (p < 0.001) and more impaired balance (p = 0.008) and falls (p = 0.004) in PSP/CBD. PD was diagnosed a median 0.96 years after index symptom. In PSP/CBD the median times from index symptom to identifying parkinsonism and then including PSP/CBD in the differential diagnosis and the final diagnosis were 1.88, 3.41 and 4.03 years, respectively (all p < 0.001). Survival from symptom onset in PSP/CBD and PD was not significantly different (5.98 vs 6.85 years, p = 0.72). More diagnoses (p < 0.001) were considered in PSP/CBD. Prior to diagnosis, PSP/CBD patients had more recurrent emergency attendances (33.3% vs 10.0%, p = 0.01) and were referred to more specialities than PD (median 5 vs 2). Time to any outpatient referral (0.70 vs 0.03 years, p = 0.025) and to specialist movement disorder review (1.96 vs 0.57 years, p = 0.002) was longer in PSP/CBD.ConclusionsThe duration and complexity of the diagnostic journey were greater in PSP/CBD than age-sex matched PD but can be improved. In this older cohort, there was little difference in survival from symptom onset in PSP/CBD and age-sex matched PD.

Analysis of the location problem of emergency attendance teams for a railroad through optimization

AbstractRail operators worldwide are seeing an increase in demand for services, driven by expanding global trade and the use of export commodities. Punctual service in a train stopped on the railroad is extremely important since the delay in service significantly impacts performance, asset utilization, and railroad productivity. The present work addresses the development and the solution of an optimization model for locating railway service teams that serve locomotives that need emergency maintenance on a Brazilian railway. Additionally, a hypercube model was solved to estimate several performance measures that assist in decision‐making. From the result analysis of different scenarios, it was found that the optimized maintenance teams' location provides superior results to the current ones considering the same resources. Also, it was possible to increase the coverage with double attendance in the studied system, monitoring different indicators such as attendance teams' average system travel time and workload.

Peri-procedural management and incidence of bleeding events following musculoskeletal injections or aspirations in people on oral anticoagulation and antiplatelet therapy.

Corticosteroid injections and aspirations are common interventions for managing musculoskeletal and inflammatory conditions. However, there remains limited safety evidence to support injection decisions and peri-procedural management in people on anti-thrombotics, particularly for direct oral anticoagulants (DOACs). To investigate peri-procedural management and bleeding complications following musculoskeletal injections or aspirations with anti-thrombotic medication use. A prospective observational study was undertaken (October 2018-December 2020) in Orthopaedics, Rheumatology and Radiology specialities in two large UK healthcare providers. Data collection involved weekly identification of musculoskeletal procedures, emergency attendance or admission within 30days and follow-up questionnaires sent within 2weeks post-procedure. Descriptive statistics were used to analyse anticoagulant/anti-platelet use, peri-procedural management and bleeding complications. Of 5080 procedures, 237 of 1338 responses reported antithrombotic use: warfarin (n=36), DOACs (n=75) and antiplatelets (n=126). There were no self-report or electronic identification of clinically significant bleeding events/complications. Only local bruising was reported (8.6% vs. 0.2% with non-use), and only with medication continuation or international normalised ratio (INR) levels ≥3.8 or unknown. Only 3/72 DOAC use was interrupted. In this study, no clinically significant bleeding events or complications were reported or identified following musculoskeletal injections or aspirations, with only localised bruising reported. It was not universal practice to check INR levels and DOAC interruption was uncommon. Findings add evidence that musculoskeletal procedures appear to be low risk procedures for bleeding complications with antithrombotic continuation and when INR levels within lower target range. Research on intra-articular or soft tissue iatrogenic consequences would add to risk/benefit evaluations.

The effectiveness of atrial fibrillation special clinic on oral anticoagulant use for high risk atrial fibrillation patients managed in the community

BackgroundService gaps exist in oral anticoagulant (OAC) use among patients with atrial fibrillation (AF) in primary care. The purpose of this study was to explore the clinical effectiveness of a community dwelling Atrial Fibrillation Special Clinic (AFSC) run by primary care physicians by evaluating its impact on OAC use and the control of modifiable cardiovascular disease (CVD) risk factors in high risk AF patients.MethodQuasi-experimental study was conducted in AFSC run by public primary care physicians in Hong Kong. Study subjects were high risk AF patients with CHA2DS2-VASc scores ≥ 2, who had been followed up (FU) at AFSC for at least one year from 01 August, 2019 to 31 October, 2020. OAC usage and modifiable CVD risk factor control were compared before and after one year of FU at AFSC. Drug-related adverse events, emergency attendance or hospitalisation episodes, survival and mortality rates after one year FU at AFSC were also reviewed.ResultsAmong the 299 high risk AF patients included in the study, significant increase in OAC use was observed from 58.5% at baseline to 82.6% after one year FU in AFSC (P < 0.001). Concerning CVD risk factor control, the average diastolic blood pressure level was significantly reduced (P = 0.009) and the satisfactory blood pressure control rate in non-diabetic patients was markedly improved after one year FU (P = 0.049). However, the average HbA1c and LDL-c levels remained static. The annual incidence rate of ischaemic stroke/systemic embolism was 0.4%, intra-cranial haemorrhage was 0.4%, major bleeding episode was 3.2% and all-cause mortality was 4.3%, all of which were comparable to reports in the literature.ConclusionAFSC is effective in enhancing OAC use and maintaining optimal modifiable CVD risk factor control among high risk AF patients managed in primary care setting, and therefore may reduce AF-associated morbidity and mortality in the long run.

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

Prehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear. To analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways. In this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019. Paramedic risk stratification and point-of-care troponin testing. The outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways. A total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations). Prehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.

External validation of the Health Care Homes hospital admission risk stratification tool in the Aboriginal Australian population of the Northern Territory.

ObjectiveThis study aimed to externally validate the Commonwealth's Health Care Homes (HCH) algorithm for Aboriginal Australians living in the Northern Territory (NT).MethodsA retrospective cohort study design using linked primary health care (PHC) and hospital data was used to analyse the performance of the HCH algorithm in predicting the risk of hospitalisation for the NT study population. The study population consisted of Aboriginal Australians residing in the NT who have visited a PHC clinic at one of the 54 NT Government clinics at least once between 1 January 2013 and 31 December 2017. Predictors of hospitalisation included demographics, patient observations, medications, diagnoses, pathology results and previous hospitalisation.ResultsThere were a total of 3256 (28.5%) emergency attendances or preventable hospitalisations during the study period. The HCH algorithm had an area under the receiver operating characteristic curve (AUC) of 0.58 for the NT remote Aboriginal population, compared with 0.66 in the Victorian cohort. A refitted model including 'previous hospitalisation' had an AUC of 0.72, demonstrating better discrimination than the HCH algorithm. Calibration was also improved in the refitted model, with an intercept of 0.00 and a slope of 1.00, compared with an intercept of 1.29 and a slope of 0.55 in the HCH algorithm.ConclusionThe HCH algorithm performed poorly on the NT cohort compared with the Victorian cohort, due to differences in population demographics and burden of disease. A population-specific hospitalisation risk algorithm is required for the NT.

NICE guidelines in the Sunderland RACPC cohort study: one size does not fit all.

At least 5% of GP and accident and emergency (A&E) attendances are undifferentiated chest pain. Rapid access chest pain clinics (RACPC) offer urgent guideline-directed management of suspected cardiac chest pain. The National Institute for Health and Care Excellence (NICE) recommends computed tomography coronary angiography (CTCA) as a first-line investigation. We evaluated the effectiveness and efficiency of a local RACPC. Retrospective analysis of unselected referrals to a RACPC in the Northeast of England was conducted for 2021. Baseline demographics and major adverse cardiovascular events (MACE) were compared between typical, atypical and non-angina. Anatomical and functional imaging results were recorded. Backward stepwise binary logistic regression modelled obstructive coronary artery disease (CAD) incidence. There were 373/401 (93.0%) patients with chest pain; 139 (37.3%) typical angina, 122 (32.8%) atypical angina and 112 (30.0%) non-angina. Typical angina patients were older (p<0.001) with more cardiovascular risk factors (p<0.001) and increased risk of obstructive CAD (adjusted odds ratio [OR] 6.27, 95% confidence interval [CI] 2.93 to 13.38) and MACE (9.4%, p=0.029). In total, 164 (44.0%) had invasive coronary angiography (ICA) within 7.4 ± 4.8 weeks; 19.5% had normal coronary arteries, 26.2% had obstructive CAD and 22.6% proceeded to invasive haemodynamic assessment ± PCI without major procedural complications. There were 39 (10.5%) who had CTCA within 34.6 ± 18.1 weeks; 25.6% needed ICA to clarify diagnosis. In conclusion, typical angina patients were at heightened risk of cardiovascular events. In the absence of adequate CTCA capacity, greater reliance on ICA still facilitated accurate diagnosis with options for immediate revascularisation, timely and safely, in the right patients. Better risk stratification and expansion of non-invasive imaging can improve local RACPC service delivery in the wider Northeast cardiology network.

Interprofessional Immersive Virtual Reality Training on Sepsis Recognition

Introduction: The implementation of evidence-based care relies on timely recognition of sepsis. Virtual reality (VR) represents a new simulation modality that can evaluate pediatric sepsis situation awareness. Methods: We evaluated situation awareness through a multiuser immersive VR experience (Fig. 1). A physician/APRN and nurse donned VR headsets to assess and provide initial management for a pediatric patient with sepsis during a team-based clinical simulation scenario. Participants were paused at 3 time points and asked to independently complete open-ended questions, including “what is the most likely cause for the patient’s clinical condition?” We compared experienced providers (nurses with ≥5 years’ experience and critical care or emergency medicine APRNs, fellows, or attendings) and novice providers (nurses with &lt;5 years’ experience and pediatric residents) recognition of sepsis. Odds ratios were calculated for sepsis recognition with group differences assessed via the T test. Results: From January to July of 2021, 144 participants (72 physicians/APRNs and 72 nurses) participated in the experience (Table 1). When assessing for recognition of sepsis at the 2-minute time point, 81% of experienced nurses (N = 48) and 50% of novices (N = 24) recognized sepsis for, on odds ratio (OR) of 4.37 (1.28–14.96), P = 0.019. For physicians/APRNs, 92% of experienced (N = 37) compared to 71% of novices (N = 35) recognized sepsis [OR, 4.61 (0.87–14.97), P = 0.078]. When combined, 85.9% of experienced clinicians (N = 85) and 62.7% of novices (N = 59) recognized sepsis [OR, 3.70 (1.15–9.07), P = 0.004]. Conclusions: These data provide validity evidence for use of this immersive VR experience for assessment and training; potentially addressing a remaining barrier to improving pediatric sepsis outcomes.

Temperature, morbidity, and behavior in milder climates

Since climate change is expected to lead to an increase in extreme weather events, several studies have considered the effects of temperature on human health, especially in countries with hotter climates. We extended this literature by modeling the relationship between temperature and morbidity in a country with a temperate maritime climate, and by considering the role of behavioral responses. Using weekly data on accident and emergency (A&E) attendances at 429 hospitals across England from 2010 to 2015, we found that while cold weather was associated with an initial reduction in A&E attendances, it appears to be a result of postponements to subsequent weeks. However, for hotter temperatures, we found substantial increases in overall attendances, which were not offset by subsequent reductions. Our results show clear effects of temperature on morbidity, even in relatively milder climates, with implications for future healthcare demand and the overall cost of climate change. • Effects of temperature on morbidity and behavior in milder climates are unclear. • We model the relationship between temperature and A&E attendances in England. • Colder temperatures lead to postponement of A&E attendances to subsequent weeks. • Hotter temperatures result in significant increases in overall A&E attendances. • Effects have implications for future healthcare demand and cost of climate change.

Case-control study developing Scottish Epilepsy Deaths Study Score to predict epilepsy-related death.

This study aimed to develop a risk prediction model for epilepsy-related death in adults. In this age- and sex-matched case-control study, we compared adults (aged ≥16 years) who had epilepsy-related death between 2009 and 2016 to living adults with epilepsy in Scotland. Cases were identified from validated administrative national datasets linked to mortality records. ICD-10 cause-of-death coding was used to define epilepsy-related death. Controls were recruited from a research database and epilepsy clinics. Clinical data from medical records were abstracted and used to undertake univariable and multivariable conditional logistic regression to develop a risk prediction model consisting of four variables chosen a priori. A weighted sum of the factors present was taken to create a risk index-the Scottish Epilepsy Deaths Study Score. Odds ratios were estimated with 95% confidence intervals (CIs). Here, 224 deceased cases (mean age 48 years, 114 male) and 224 matched living controls were compared. In univariable analysis, predictors of epilepsy-related death were recent epilepsy-related accident and emergency attendance (odds ratio 5.1, 95% CI 3.2-8.3), living in deprived areas (odds ratio 2.5, 95% CI 1.6-4.0), developmental epilepsy (odds ratio 3.1, 95% CI 1.7-5.7), raised Charlson Comorbidity Index score (odds ratio 2.5, 95% CI 1.2-5.2), alcohol abuse (odds ratio 4.4, 95% CI 2.2-9.2), absent recent neurology review (odds ratio 3.8, 95% CI 2.4-6.1) and generalized epilepsy (odds ratio 1.9, 95% CI 1.2-3.0). Scottish Epilepsy Deaths Study Score model variables were derived from the first four listed before, with Charlson Comorbidity Index ≥2 given 1 point, living in the two most deprived areas given 2 points, having an inherited or congenital aetiology or risk factor for developing epilepsy given 2 points and recent epilepsy-related accident and emergency attendance given 3 points. Compared to having a Scottish Epilepsy Deaths Study Score of 0, those with a Scottish Epilepsy Deaths Study Score of 1 remained low risk, with odds ratio 1.6 (95% CI 0.5-4.8). Those with a Scottish Epilepsy Deaths Study Score of 2-3 had moderate risk, with odds ratio 2.8 (95% CI 1.3-6.2). Those with a Scottish Epilepsy Deaths Study Score of 4-5 and 6-8 were high risk, with odds ratio 14.4 (95% CI 5.9-35.2) and 24.0 (95% CI 8.1-71.2), respectively. The Scottish Epilepsy Deaths Study Score may be a helpful tool for identifying adults at high risk of epilepsy-related death and requires external validation.