Spanish Emergency Departments Research Articles

Management and serious risk factors associated with unintentional injuries in paediatric emergencies in Spain

IntroductionThirty-eight million patients with injuries are treated in Emergency Departments every year, 90% of them being in the form of unintentional injuries (UIs). There are currently no global records of its management in Spain, or the risk factors that may be associated with them. The objective of this study is to describe the management of UIs in Spanish paediatric emergency departments, and to analyse factors related to the presence of serious injuries. Material and methodsA sub-study of a prospective multicentre observational study conducted over 12 months in 11 hospitals of the Spanish Paediatric Emergency Research Group (RiSEUP-SPERG), including children from 0 to 16 years of age consulting for UIs. Epidemiological data, circumstances of the injury, and data on emergency care and discharge destination were recorded on the 13th day of each month. ResultsA total of 10,175 episodes were recorded, of which 1,941 were UIs 19.1%), including 1,673, of which 257 (15.4%) were severe. The most frequent complementary test was simple radiography (60.0%), and the most frequent procedure was limb immobilisation (38.6%). A significant relationship was found between presenting with a severe UI and age >5 years [OR 2.24 (95% CI: 1.61–3.16)], history of fracture [OR 2.05 (95% CI: 1.22–3.43)], or sports activity as a mechanism of injury [OR 1.76 (95% CI: 1.29–2.38)], among others. ConclusionIn Spain, most UIs are not serious. X-rays and immobilisation of extremities are the most frequently performed tests and procedures. Severe UIs were associated with individual factors, such as age >5 years or history of fracture, and with sports activity as a mechanism associated with severity. It is vital to implement measures to improve the prevention of these injuries and to support the training of caregivers through educational programmes.

Frequency of five unusual presentations in patients with COVID-19: results of the UMC-19-S1

Despite SARS-CoV-19 infection has a stereotypical clinical picture, isolated cases with unusual manifestations have been reported, some of them being well-known to be triggered by viral infections. However, the real frequency in COVID-19 is unknown. Analysing data of 63 822 COVID patients attending 50 Spanish emergency department (ED) during the COVID outbreak, before hospitalisation, we report frequencies of (myo)pericarditis (0.71‰), meningoencephalitis (0.25‰), Guillain-Barré syndrome (0.13‰), acute pancreatitis (0.71‰) and spontaneous pneumothorax (0.57‰). Compared with general ED population, COVID patients developed more frequently Guillain-Barré syndrome (odds ratio (OR) 4.55, 95% confidence interval (CI) 2.09-9.90), spontaneous pneumothorax (OR 1.98, 95% CI 1.40-2.79) and (myo)pericarditis (OR 1.45, 95% CI 1.07-1.97), but less frequently pancreatitis (OR 0.44, 95% CI 0.33-0.60).

Epidemiology of acute pediatric poisonings in Spain: a prospective multicenter study from the Spanish Society of Pediatric Emergency Medicine.

To identify types of childhood poisoning exposures leading to consultation to emergency departments (ED) in Spain. We carried out a multicenter prospective registry-based cohort study including children with acute poisonings presenting to 55 pediatric EDs of the Spanish Society of Pediatric Emergency Medicine between 2008 and 2017, during previously designated certain days. During the study period, we registered 749 803 pediatric ED presentations, of which 1749 were for poisonings (0.23%). Most commonly involved toxicants were therapeutic drugs (845, 48.3%), household products (387, 22.1%), ethanol (168, 9.6%), cosmetics (88, 5%) and CO (73, 4.2%). We identified five types of poisoning presentations. Two types occurring at home involving young children accounted for 1368 episodes (78.2%): non-intentional ingestions and dosage error of therapeutic drugs (791, 45.2%), and non-intentional ingestions of household products and cosmetics (577, 33%). Most commonly involved toxicants were benzodiazepines and detergents in each group. The remaining three groups required more interventions in the ED and had a lower rate of outpatient management: intentional ingestion of therapeutic drugs (105, 6%, frequently suicide attempts, mainly with benzodiazepines or combinations of therapeutic drugs), non-intentional inhalation of CO (76, 4.3%) and recreational ingestion of ethanol or use of illicit drugs (200, 11.4%). The distribution of these groups showed differences related to sex, domestic habits of storage of toxicants, symptoms, management in the ED and patient disposition. We identified five different types of childhood poisoning presentations to Spanish EDs. Best practices need to be identified for prevention of these episodes. European Journal of Emergency Medicine XXX: 000-000 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Identification of Senior At Risk scale predicts 30-day mortality among older patients with acute heart failure

ObjectiveTo assess the value of frailty screening tool (Identification of Senior at Risk [ISAR]) in predicting 30-day mortality risk in older patients attended in emergency department (ED) for acute heart failure (AHF). DesignObservational multicenter cohort study. SettingOAK-3 register. SubjectsPatients aged ≥65 years attended with ADHF in 16 Spanish EDs from January to February 2016. InterventionNo. VariablesVariable of study was ISAR scale. The outcome was all-cause 30-day mortality. ResultsWe included 1059 patients (mean age 85±5.9 years old). One hundred and sixty (15.1%) cases had 0–1 points, 278 (26.3%) 2 points, 260 (24.6%) 3 points, 209 (19.7%) 4 points, and 152 (14.3%) 5–6 points of ISAR scale. Ninety five (9.0%) patients died within 30 days. The percentage of mortality increased in relation to ISAR category (lineal trend P value<.001). The area under curve of ISAR scale was 0.703 (95%CI 0.655–0.751; P<.001). After adjusting for EFFECT risk categories, we observed a progressive increase in odds ratios of ISAR scale groups compared to reference (0–1 points). Conclusionsscale is a brief and easy tool that should be considered for frailty screening during initial assessment of older patients attended with AHF for predicting 30-day mortality.

A multidrug-resistant microorganism infection risk prediction model: development and validation in an emergency medicine population.

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p < 0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74-0.78) in the derivation cohort and 0.72 (CI 95% 0.70-0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0-2 points), 16% (3-5 points), 24% (6-9 points), 33% (10-14 points), 47% (15-21 points), and 71% (> 21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments

The objective of the InMEDIATE study was to evaluate the change in intensity of traumatic pain over the first 20 min in adult patients treated with methoxyflurane versus standard analgesic treatment in Spain. This the first randomized, active-controlled, multicenter trial of methoxyflurane in the emergency setting in Europe. This was a randomized, controlled study that enrolled adult patients with acute moderate to severe (score ≥4 on the 11-point Numeric Rating Scale) trauma-associated pain in 14 Spanish emergency departments. Patients were randomized 1:1 to methoxyflurane (up to 2×3 mL) or standard analgesic treatment. Coprimary endpoints were the change from baseline in Numeric Rating Scale pain intensity score during the first 20 minutes of treatment and time to first pain relief. Three hundred five patients were randomized (methoxyflurane 156; standard analgesic treatment 149). Most patients in the standard analgesic treatment group (70%) received intravenous first-step analgesics and 9.4% of patients were treated with opioids. Mean decrease from baseline in Numeric Rating Scale pain intensity score was greater for methoxyflurane than standard analgesic treatment at all points, with a significant treatment difference overall up to 20 minutes (repeated-measures model 2.47 versus 1.39; treatment difference 1.00; 95% confidence interval 0.84 to 1.32). Median time to first pain relief was significantly shorter for methoxyflurane than standard analgesic treatment (3 versus 10 minutes). Methoxyflurane achieved better patient and clinician ratings for pain control and comfort of treatment than standard analgesic treatment and exceeded patient and clinician expectations of treatment in, respectively, 77% and 72% of cases compared with 38% and 19% for standard analgesic treatment. These results support consideration of methoxyflurane as a nonnarcotic, easy-to-administer, rapid-acting, first-line alternative to currently available analgesic treatments for trauma pain.

P4538Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in emergency departments

Abstract Introduction There is a need to explore the risk of malnutrition as a modifiable prognostic factor in order to establish routine screening of malnutrition in the emergency setting among older patients with acute heart failure (AH. Objectives To determine the impact of risk of malnutrition on 30-day mortality risk among older patients attended for AHF in the Emergency Department (ED). Methodology We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attended with AHF in 16 Spanish EDs over a 2-month period (January-February 2016). Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) &lt;12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality. Results We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1=3.4; 95% CI 1.2–9.7; p=0.020 and adjusted OR by model 2=3.2; 95% CI 1.1–9.2; p=0.030) compared to normal nutritional status. Conclusions The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients attended with AHF in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan. Acknowledgement/Funding Spanish Ministry of Health and FEDER (PI 18/00456, PI 18/00393, PI 17/00972, PI17/1732, PI15/00773, PI15/01019, and PI11/01021)

Editor's Choice- Impact of identifying precipitating factors on 30-day mortality in acute heart failure patients.

The aim of this study was to describe the prevalence and prognostic value of the most common triggering factors in acute heart failure. Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in three time periods between 2011 and 2016. Precipitating factors were classified as: (a) unrecognized; (b) infection; (c) atrial fibrillation; (d) anaemia; (e) hypertension; (f) acute coronary syndrome; (g) non-adherence; and (h) two or more precipitant factors. Unadjusted and adjusted logistic regression models were used to assess the association between 30-day mortality and each precipitant factor. The risk of dying was further evaluated by week intervals over the 30-day follow-up to assess the period of higher vulnerability for each precipitant factor. Approximately 69% of our 9999 patients presented with a triggering factor and 1002 died within the first 30 days (10.0%). The most prevalent factors were infection and atrial fibrillation. After adjusting for 11 known predictors, acute coronary syndrome was associated with higher 30-day mortality (odds ratio (OR) 1.87; 95% confidence interval (CI) 1.02-3.42), whereas atrial fibrillation (OR 0.75; 95% CI 0.56-0.94) and hypertension (OR 0.34; 95% CI 0.21-0.55) were significantly associated with better outcomes when compared to patients without precipitant. Patients with infection, anaemia and non-compliance were not at higher risk of dying within 30 days. These findings were consistent across gender and age groups. The 30-day mortality time pattern varied between and within precipitant factors. Precipitant factors in acute heart failure patients are prevalent and have a prognostic value regardless of the patient's gender and age. They can be managed with specific treatments and can sometimes be prevented.

180-Day functional decline among older patients attending an emergency department after a fall

ObjectivesTo determine functional changes and factors affecting 180-day functional prognosis among older patients attending a hospital emergency department (ED) after a fall. Study designRetrospective analysis from a prospective cohort study (FALL-ER Registry) spanning one year that included individuals aged ≥65 years attending four Spanish EDs after a fall. We collected 9 baseline and 6 fall-related factors. Main outcome measuresBarthel Index (BI) was measured at baseline, discharge and 30, 90 and 180 days after the index fall. Absolute and relative BI changes were calculated. Absolute difference of ≥10 points between BI at baseline and at 180 days was considered a clinically significant functional decline. Results452 patients (mean age 80 ± 8 years; 70.8% women) were included. Baseline BI was 79.3 ± 23.1 points. Compared with baseline, functional status was significantly lower at the 4 follow-up time points (-8.7% at discharge; and −6.9%, −7.9% and −9.5% at 30, 90 and 180 days; p < 0.001 for all comparisons in relation to baseline; p = 0.001 for change over time). One hundred and thirty-three (29.6%) patients had a clinically significant functional decline at 180 days. Age ≥85 years (OR = 2.24, 95%CI 1.23–4.08; p = 0.008), fall-related fracture (OR = 2.45, 95%CI 1.43–4.28; p = 0.001), hospitalization (OR = 1.91; 95%CI 1.11–3.29; p = 0.019) and post-fall syndrome (OR = 1.77, 95%CI 1.13-2.77; p = 0.013) were independently associated with 180-day clinically significant functional decline. ConclusionPatients ≥65 years attending EDs after a fall experience a consistent and persistent negative impact on their functional status. Several factors may help identify patients at increased risk of functional impairment.

Management and serious risk factors associated with unintentional injuries in paediatric emergencies in Spain

Thirty-eight million patients with injuries are treated in Emergency Departments every year, 90% of them being in the form of unintentional injuries (UIs). There are currently no global records of its management in Spain, or the risk factors that may be associated with them. The objective of this study is to describe the management of UIs in Spanish paediatric emergency departments, and to analyse factors related to the presence of serious injuries. A sub-study of a prospective multicentre observational study conducted over 12months in 11hospitals of the Spanish Paediatric Emergency Research Group (RiSEUP-SPERG), including children from 0 to 16years of age consulting for UIs. Epidemiological data, circumstances of the injury, and data on emergency care and discharge destination were recorded on the 13th day of each month. A total of 10,175 episodes were recorded, of which 1,941 were UIs (19.1%), including 1,673, of which 257 (15.4%) were severe. The most frequent complementary test was simple radiography (60.0%), and the most frequent procedure was limb immobilisation (38.6%). A significant relationship was found between presenting with a severe UI and age >5 years (OR2.24; 95%CI: 1.61-3.16), history of fracture (OR2.05; 95%CI: 1.22-3.43), or sports activity as a mechanism of injury (OR1.76; 95%CI: 1.29-2.38), among others. In Spain, most UIs are not serious. X-rays and immobilisation of extremities are the most frequently performed tests and procedures. Severe UIs were associated with individual factors, such as age >5years or history of fracture, and with sports activity as a mechanism associated with severity. It is vital to implement measures to improve the prevention of these injuries and to support the training of caregivers through educational programmes.

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes.

To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion=warm; hypoperfusion=cold) and congestion (not=dry; yes=wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400-1.968) and cold + dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival.

Management of anaphylaxis in Spain: pediatric emergency care providers' knowledge.

Acute care providers must diagnose and treat patients with anaphylaxis. The objective was to analyze Spanish pediatric emergency departments' (ED) providers' knowledge of the international recommendations for the management of anaphylaxis. A web-based survey including providers (both attending and residents) from seven Spanish pediatric EDs was conducted. To analyze the knowledge of the identification of anaphylaxis, we used the diagnostic criteria given by the National Institute of Allergy and Infectious Disease and Food Allergy and the Food Allergy and Anaphylaxis Network (2005). To analyze the management, we used the practical recommendations on the management of anaphylaxis published by the Joint Task Force on Practice Parameters (2014). A total of 425 physicians received the link and 337 (79.2%) completed the survey (138 attending, 76.6%; 199 residents, 81.2%, P<0.05). More than 90% of the providers correctly identified the anaphylaxis, except for not diagnosing it when reduced blood pressure is detected after exposure to a known allergen (69.7%) and misdiagnosis of anaphylaxis in patients with progressive urticaria with significant angioedema (65.9%). Nearly 100% identified epinephrine as the first-line treatment. Main failures of treatment were related to the position of the patient, the effect of medications in preventing a biphasic reaction, the recommended time to observe patients, and those related to the follow-up. No significant differences were found between attendings and residents. Even though the Spanish pediatric ED providers' knowledge of the management of anaphylaxis is good, certain improvement areas are identified in both the identification and the management of these patients.

Analysis of How Emergency Physicians’ Decisions to Hospitalize or Discharge Patients With Acute Heart Failure Match the Clinical Risk Categories of the MEESSI-AHF Scale

The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure patients. The objective of this study is to compare the distribution of risk categories between hospitalized and discharged ED patients with acute heart failure. We included consecutive acute heart failure patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI-AHF risk categories. We calculated the odds of hospitalization (versus direct discharge from the ED) across MEESSI-AHF risk categories. Next, we assessed the following 30-day postdischarge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low- and increased-risk categories. We included 7,930 patients (80.5 years [SD 10.1 years]; women 54.7%; hospitalized 75.3%). Compared with that for low-risk MEESSI-AHF patients, odds ratios for hospitalization of patients in intermediate-, high-, and very-high-risk categories were 1.83 (95% confidence interval [CI] 1.64 to 2.05), 3.05 (95% CI 2.48 to 3.76), and 3.98 (95% CI 3.13 to 5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as being at increased risk by MEESSI-AHF, and 19.0% of all the increased-risk patients were discharged from the ED. Among the low-risk MEESSI-AHF patients, the 30-day postdischarge mortality did not differ by ED disposition (hazard ratio [HR] for discharged patients with respect to hospitalized ones 0.65; 95% CI 0.70 to 1.11), nor did it differ in the increased-risk group (HR 0.88; 95% CI 0.63 to 1.23). The discharged low-risk MEESSI-AHF patients had higher risks of 30-day ED revisit and hospitalization (HR 1.86, 95% CI 1.57 to 2.20; and HR 1.92, 95% CI 1.54 to 2.40, respectively) compared with the admitted patients, as did the discharged patients in the increased-risk group (HR 1.62, 95% CI 1.39 to 1.89; and HR 1.40, 95% CI 1.16 to 1.68, respectively), with similar results for the combined endpoint. The disposition decisions made in current clinical practice for ED acute heart failure patients calibrate with MEESSI-AHF risk categories, but nearly half of the patients currently discharged from the ED fall into increased-risk MEESSI-AHF categories.

Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in Emergency Departments

BackgroundLittle is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF. Material and methodsWe performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality. ResultsWe included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95%CI 1.2–9.7; p = .020 and adjusted OR by model 2 = 3.1; 95%CI 1.1–9.0; p = .033) compared to normal nutritional status. ConclusionsThe risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.

Point of care ultrasound knowledge among resident doctors in Madrid's university hospitals. Influence of the induction in emergency departments with point of care ultrasound practice

Abstract Background Point of care ultrasound study (POCUS) is a relatively new technique in Spanish Emergency Departments (EDs). Nonetheless, its use is increasing, and the number of emergency doctors and the number of papers published in our country has skyrocketed in last decade. Despite this fact, there is still no evidence of how POCUS is taught in our medical schools. Objective To ascertain the level of knowledge about POCUS in first year resident doctors of three hospitals in Madrid, and one year after having worked in ED with POCUS practice. Methods and study design The study looked at demographic aspects, POCUS knowledge, and opinions about its usefulness in the ED, prior to and after working in ED with routine use of POCUS. Results Of the 265 questionnaires, 197 were first-year residents (Group 1) and 68 second-year residents (Group 2). Another 55 senior medical students completed the questionnaire (Group 3). The majority of Groups 1 and 3 stated to have a very low POCUS level. Almost three-quarters (73%) of Group 2 stated having an intermediate or high level, and 26% even declared having full knowledge. More than half of the students agreed that POCUS was a useful tool in ED. Conclusions There is a low level of knowledge about POCUS among first-year residents. After working in POCUS qualified EDs, these resident doctors state both the importance and their higher level of knowledge of POCUS.

PP133 Ensuring Secure Health Data Exchange Across Europe. The SHIELD Project

IntroductionData exchange protection is one of the main challenges in e-health. Nowadays, many people move from one country to another for various reasons, even though they may have chronic diseases or multiple pathologies. The main objective of the SHIELD project is to create an open and extendable security architecture, with supported privacy mechanisms that citizens can trust, to provide systematic protection for the storage and exchange of health data across European borders.MethodsepSOS is a European project that deals with the security and interoperability of e-health data, and has developed an Open National Contact Point (OpenNCP) architecture. For the initial validation of the framework, two OpenNCP virtual nodes were used to simulate the real nodes between Italy and Spain. For secure data exchange, different prototype tools were designed: end-to-end user interfaces (profiles for administrative staff, nurses, physicians, etc.); sensitivity and data hiding tools; consent management tools; report translation tools; and mobile device tampering detection tools.ResultsValidation scenarios (realistic use cases) were developed in Italy, Spain, and the United Kingdom. The first scenario was an Italian citizen traveling to Spain who has an acute emergency episode (e.g. stroke) and loses consciousness. The Spanish emergency department physician assisting the patient checks the patient's health record. The first round of SHIELD framework validations was successfully completed, and the results were presented to the European Commission.ConclusionsSecurity challenges need to be addressed when assessing e-health solutions. The challenges include issues with interoperability, confidentiality, availability, integrity, privacy, ethics, regulations, and e-health data. In addition, decisions must be made as to which data will be shared and how. The results of the initial validations provide a basis for the in-depth requirements analysis and for setting the main pillars of the SHIELD architecture design.

Nurses’ and doctors’ perception of triage system in a Spanish Clinical University Hospital Emergency Department

Objective: in most of the Emergency Services of Spain, triage is carried out by nurses. The objective of this study was to know the level of satisfaction in nursing and medical staff on the dynamics of the Emergency Department (ED), determined by the current triage system in their workplace, carried out since 2012 exclusively by nurses, as well as the opinion on the level of knowledge of triage of both nurses and medical staff and their perception of the quality of their specific training on triage. Methods: cross-sectional descriptive study by ad hoc questionnaire to nurses and doctors of the ED of a University Clinical Hospital. Results: the global participation was 71.9% (n = 82, 82.3% nurses and 60% doctors). Regarding the dynamics of the ED determined by the current triage system, 45.1% of the staff is moderately satisfied. Regarding the perception of knowledge about triage, 78% of the total thinks that both the training of the nurses and doctors is between enough and good. 75.9% of the nursing staff has received a course on triage, compared to 70.8% of the doctors who have not received it. Both groups say that the collaboration between the two would be the ideal way to carry out the work of triage. Conclusions: after the implementation of the current system, both nurses and doctors are moderately satisfied with the dynamics of the ED, believe that the knowledge of both groups on triage is acceptable and claim that the best way to do it is through collaboration between both professionals.

Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments

ObjectivesTo offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents. MethodsA multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016. ResultsA total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95% CI: 72.7–79.4%), partial in 138 (21.7%; 95% CI: 18.5–24.9%), and poor in 14 (2.2%; 95% CI: 1.1–3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95% CI: 1.10–8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95% CI: 1.68–3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95% CI: 1.09–1.28 and OR: 1.86; 95% CI: 1.22–2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95% CI: 11.78–50.76). The perceived satisfaction level (0–10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70). ConclusionsThe sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.

Comparative Analysis of Short-Term Outcomes of Patients With Heart Failure With a Mid-Range Ejection Fraction After Acute Decompensation

To determine short-term outcomes after an episode of acute heart failure in patients with mid-range ejection fraction (40%-49%; HFmrEF) compared with patients with reduced (<40%) and preserved (>49%) ejection fractions (HFrEF and HFpEF, respectively) and according to their final destination after emergency department (ED) care. This is an exploratory, secondary analysis of the Epidemiology of Acute Heart Failure in the Emergency departments Registry, which includes consecutive acute heart failure patients diagnosed in 41 Spanish EDs. Patients with echocardiography data were included and divided into HFrEF, HFmrEF, and HFpEF. The primary outcome was 30-day all-cause mortality, and secondary outcomes were in-hospital all-cause mortality, hospital length of stay >10 days, and 30-day postdischarge ED revisit due to AHF and combined end point (ED revisit and/or death). We included 6,856 patients (age 79 [10]; 52.1% women): 21.6% had HFrEF, 14.3% HFmrEF, and 64.1% HFpEF. The main destinations for the 982 HFmrEF patients after ED management were internal medicine (293, 29.8%), cardiology (194, 19.9%) and not hospitalized (241, 24.5%), whereas the remaining 254 patients were admitted to other departments, including geriatric wards, short-stay units and intensive care units. Outcomes for HFmrEF did not differ compared with either HFrEF or HFpEF. Compared with HFmrEF admitted to cardiology, internal medicine admission or direct ED discharge increased the 30-day postdischarge ED revisit (hazard ratio [HR] 1.713, 95% confidence interval [CI] 1.042 to 2.816; and HR 1.683, 95% CI 1.046 to 2.708, respectively) and the 30-day postdischarge combined end point (HR 1.732, 95% CI 1.070 to 2.803; and HR 1.727, 95% CI 1.083 to 2.756, respectively). In conclusion, patients in the newly created HFmrEF category suffering from an acute decompensation have similar short-term outcomes as those in the classical HFrEF and HFpEF categories; nonetheless, HFmrEF patients handled in cardiology wards during decompensation obtain better outcomes, and reasons for these differences have to be unmasked and corrected.

Characteristics and outcomes of older adults presented to Spanish emergency departments after a fall.

To study patient profile, fall-related characteristics and immediate outcomes according to age and to determine the effect of age in the outcomes among older patients presenting to ED after a fall. Cross-sectional analysis of the FALL-ER registry that included patients aged ≥ 65years old that presented to five Spanish EDs after a fall. Patients were classified into three age categories, and demographic, comorbidity, chronic medication, fall-related characteristics, health care resources and immediate outcomes data were analysed. We included 1610 patients, 541 (28%) aged 65-74, 647 (40.2%) aged 74-84 and 512 (31.8%) aged ≥ 85years old. Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. Medications related to risk of falling and antithrombotic therapy significantly increased with age category. Physical, functional and psychological consequences and healthcare resource use increased significantly with age group. Age was independently associated with severe injury (adjusted OR 1.02; IC 95% 1.01-1.04), fear of falling (adjusted OR 1.02; IC 95% 1.01-1.04) and acute functional impairment (adjusted OR 1.02; IC 95% 1.00-1.04). Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. The probability of presenting with severe injury, fear of falling and acute functional impairment increases with age.