Editor’s note: The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine. The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health.Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine.
African Journal of Emergency Medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria, and the Rwanda Emergency Care Association.
Impact of lockdown measures implemented during the COVID-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa
Morris D, Rogers M, Kissmer N, Du Preez A, Dufourq N
Morris et al. Afr J Emerg Med 2020; 10(4): 193–196.
https://doi.org/10.1016/j.afjem.2020.06.005
Introduction: The COVID-19 pandemic triggered unprecedented nationwide regulations aimed primarily at slowing the spread of the virus. The objective of this study was to describe the effect of these regulations on the number and severity of trauma presentations to a regional emergency department in Kwa-Zulu Natal.
Methods: A retrospective cohort study of the triage register at Edendale Hospital Emergency Department was conducted, comparing all trauma presentations in the month of April 2020 with those from the preceding 2 years. The number of patients, mechanism of trauma, and severity of illness were recorded and compared.
Results: A 47% reduction in the number of trauma cases was recorded for April 2020. The proportion of severe cases did not change. The categories showing a major decrease were motor vehicle accidents, pedestrian vehicle accidents, assault, and gunshot wounds. The incidence of dog bite wounds and burns remained unchanged.
Conclusion: This study shows that the burden of trauma presenting to the emergency department was decreased in the month of April 2020 by the regulations implemented in response to the COVID-19 pandemic.
Reproduced with permission
Emergency department management of traumatic brain injuries: a resource-tiered review
Dixon J, Comstock G, Whitfield J, Richards D, Burkholder TW, Leifer N, Mould-Millman NK, Calvello Hynes EJ
Dixon et al. Afr J Emerg Med 2020; 10(3): 159–166.
doi: 10.1016/j.afjem.2020.05.006.
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.
Objectives: Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource-tiered framework.
Methods: A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource-tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.
Recommendations: Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.
Reproduced with permission
Canadian Journal of Emergency Medicine
http://caep.ca/resources/cjem/
Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department
Ian G Stiell, Lisa Mielniczuk, Heather D Clark, Guy Hebert, Monica Taljaard, Alan J Forster, George A Wells, Catherine M Clement, Jennifer Brinkhurst, Erica L Brown, Marie-Joe Nemnom and Jeffrey J Perry
(Scheduled for March 2021 Issue)
Stiell et al. Can J Emerg Med 2021.
doi:10.1007/s43678-020-00047-xs
Introduction: Acute heart failure patients often have an uncertain or delayed follow-up after discharge from the emergency department (ED). Our goal was to introduce rapid-access specialty clinics to ensure acute heart failure patients were seen within 7 days, in an effort to reduce admissions and improve follow-up care.
Methods: This prospective cohort study was conducted at two campuses of a large tertiary care hospital. We enrolled acute heart failure patients who presented to the ED with shortness of breath and were later discharged. Following a 12-month before period, we introduced rapid-access acute heart failure clinics staffed by cardiology and internal medicine. We allowed for a 3-month implementation period and then observed outcomes over the subsequent 12-month after period. The primary outcome was hospital admission within 30 days. Secondary outcomes included mortality and actual access to specialty care.
Results: Patients in the before (N = 355) and after periods (N = 374) were similar for age and most characteristics. Segmented autoregression analysis demonstrated there was a pre-existing trend to fewer admissions. Attendance at a specialty clinic increased from 17.8% to 42.1% (P < 0.01) and the median days to the clinic decreased from 13 to 6 days (P < 0.01). Thirty-day mortality did not change.
Conclusions: Implementation of rapid-access clinics for acute heart failure patients discharged from the ED did not lead to an overall decrease in hospital admissions. It did, however, lead to increased access to specialist care, reduced follow-up times, without an increase in return ED visits or mortality. Widespread use of this rapid-access approach to a specialist can improve care for acute heart failure patients discharged home from the ED.
Keywords: Heart failure, emergency department, patient safety
MARCH 2020:
Factors associated with revisits by patients with SARS-CoV-2 infection discharged from a hospital emergency department
Beatriz López-Barbeito, Ana García-Martínez, Blanca Coll-Vinent, Arrate Placer, Carme Font, Carmen Rosa Vargas, Carolina Sánchez, Daniela Piñango, Elisenda Gómez-Angelats, David Curtelin, Emilio Salgado, Francisco Aya, Gemma Martínez-Nadal, José Ramón Alonso, Julia García-Gozalbes, Leticia Fresco, Miguel Galicia, Milagrosa Perea, Miriam Carbó, Nerea Iniesta, Ona Escoda, Rafael Perelló, Sandra Cuerpo, Vanesa Flores, Xavier Alemany, Óscar Miró, Mª del Mar Ortega, en representación del Grupo de Trabajo sobre la atención
de la COVID-19 en Urgencias (COVID19-URG).
Cited: López-Barbeito B, García-Martínez A, Coll-Vinent B, Placer A, Vargas CR, Sánchez C, et al. Factors associated with revisits by patients with SARS-CoV-2 infection discharged from a hospital emergency department. Emergencias 2020; 32: 386–394.
Objective: To analyze emergency department (ED) revisits from patients discharged with possible coronavirus disease 2019 (COVID-19).
Methods: Retrospective observational study of consecutive patients who came to the ED over a period of 2 months and were diagnosed with possible COVID-19. We analyzed clinical and epidemiologic variables, treatments given in the ED, discharge destination, need to revisit, and reasons for revisits. Patients who did or did not revisit were compared, and factors associated with revisits were explored.
Results: The 2378 patients included had a mean age of 57 years; 49% were women. Of the 925 patients (39%) discharged, 170 (20.5%) revisited the ED, mainly for persistence or progression of symptoms. Sixty-six (38.8%) were hospitalized. Odds ratios (ORs) for the following factors showed an association with revisits: history of rheumatologic disease (OR, 2.97; 95% CI, 1.10–7.99; P = 0.03), digestive symptoms (OR, 1.73; 95% CI, 1.14–2.63; P = 0.01), respiratory rate over 20 breaths per minute (OR, 1.03; 95% CI, 1.0–1.06; P = 0.05), and corticosteroid therapy given in the ED (OR, 7.78; 95% CI, 1.77–14.21, P = 0.01). Factors associated with hospitalization after revisits were age over 48 years (OR, 2.57; 95% CI, 1 42–4.67; P = 0.002) and fever (OR, 4.73; 95% CI, 1.99–11.27; P = 0.001).
Conclusions: Patients under the age of 48 years without comorbidity and with normal vitals can be discharged from the ED without fear of complications. A history of rheumatologic disease, fever, digestive symptoms, and a respiratory rate over 20 breaths per minute, or a need for corticosteroid therapy were independently associated with revisits. Fever and age over 48 years were associated with a need for hospitalization.
Keywords: COVID-19. SARS-CoV-2. Emergency health services. Revisits.
Annals of Emergency Medicine
(The print version of this article has been scheduled for March 2021)
Routine use of a Bougie improves first-attempt intubation success in the out-of-hospital setting
Andrew J Latimer, MD, Brenna Harrington, Catherine R Counts, PhD, MHA, Katelyn Ruark, Charles Maynard, PhD, Taketo Watase, MD, Michael R Sayre, MD
Study objective: The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie.
Methods: A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate.
Results: Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% (95% confidence interval 3% to 11%)). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio, 2.82 (95% confidence interval, 1.96 to 4.01)).
Conclusion: Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.
How to cite this article:
Latimer, AJ, Harrington, B, Counts, CR, et al. Routine use of a bougie improves first-attempt intubation success in the out-of-hospital setting. 2020.
https://doi.org/10.1016/j.annemergmed.2020.10.01.
Annals of Emergency Medicine
(The print version of this article has been scheduled for April 2021)
When safety event reporting is seen as punitive
V Ramana Feeser, MD, Anne K Jackson, RN, MS, Nastassia M Savage, PhD, Timothy A Layng, DO, Regina K Senn, RN, Harinder S Dhindsa, MD, MPH, Sally A Santen, MD, PhD, Robin R Hemphill, MD, MPH
Study objective: Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs.
Methods: Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ = 0.84–0.92), and identified relationships between PSN characteristics and punitive reporting were described.
Results: A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%).
Conclusion: Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.
How to cite this article:
Feeser VR, Jackson AK, Savage NM, et al. when safety event reporting is seen as punitive. 2020.
https://doi.org/10.1016/j.annemergmed.2020.06.048.
