Emergency Medicine Journal最新文献

Trauma remains a significant cause of mortality and morbidity. Non-compressible torso haemorrhage is one of the key drives of these mortality data. Our contemporary management has focused on damage control resuscitation, with a focus on haemorrhage control, haemostatic resuscitation and permissive hypotension. The evidence for permissive hypotension lacks the robustness as other treatments, such as tranexamic acid. Despite this clinicians still target arbitrary systolic blood pressure cutoffs as both goals and ceilings of therapy. In this paper, we suggest that perhaps more consideration should be given to the diastolic blood pressure in bleeding trauma patients. The diastolic blood pressure is critical for coronary perfusion, and in turn the cardiac output responsible for cerebral blood flow. We suggest that a move to reframing resuscitation in terms of physiology may change the way that we resuscitate these patients and allow for more nuanced treatment strategies.

Background: Growing numbers of avoidable low-acuity visits to emergency departments (ED) are a major health policy concern globally and are thought to contribute to ED crowding. This study explores the differences in the utilisation of low-acuity ED visits between culturally and linguistically diverse (CaLD) migrants and English-speaking background (ESB) population.

Methods: A study based on a cross-sectional survey of individuals aged 45 or over linked to routinely collected ED visit records in New South Wales. We employed a negative binomial regression model to compare the number of yearly low-acuity ED visits between individuals from ESB and CaLD backgrounds after adjusting for relevant health-related and sociodemographic characteristics.

Results: We analysed 227 681 individuals with a mean age of 61, two-thirds of whom came from an ESB. Among individuals with a CaLD background, only those born in Australia had comparable rates of low-acuity ED visits as those with an ESB. In contrast, individuals with CaLD backgrounds who were born overseas were significantly less likely to make low-acuity visits to the ED compared with those from an ESB irrespective of year of arrival-for those who had migrated less than 20 years ago (relative risk (RR) 0.72, 95% CI 0.62 to 0.83) and those who migrated more than 20 years ago (RR 0.91, 95% CI 0.88 to 0.95).

Conclusion: Foreign-born migrants aged 45 and over from CaLD backgrounds tend to have the lowest rates of low-acuity ED visits, particularly those who migrated more recently indicating low-acuity visits by CaLD patients are unlikely to contribute to ED crowding.

Background: Pulse oximetry measures oxygen saturation non-invasively by using differential absorption of infrared signals which are dependent on the oxyhaemoglobin:deoxyhaemoglobin ratio. We tested the hypothesis that pulse oximetry error in measurements of blood oxygen saturations may be associated with blood haemoglobin levels.

Methods: The study design was an observational study of all adult patients admitted to a large teaching hospital with suspected or confirmed COVID-19 infection from February 2020 to December 2021 who had arterial blood gases (ABG) drawn. The pulse oximetry reading was compared with the arterial saturation on the ABG and the measurement error was determined according to the ABG haemoglobin. A secondary analysis was performed among a subset of patients with venous haemoglobins drawn within 24 hours, comparing measurement error between ABG arterial saturation and pulse oximetry readings between those with normal (150 g/L) and low (70 g/L) haemoglobins.

Results: The analysis used 5922 paired oxygen saturations from 3994 patients with contemporaneous haemoglobin measurements by ABG. A 1 g/L decrease in blood haemoglobin was associated with an 0.021% (95% CI: +0.008% to +0.033%) increase in the measurement error (in the direction of a falsely elevated reading.). In the 1086 patients who had had a venous haemoglobin there was a 0.055% (95% CI: +0.020% to +0.090%) increase in the measurement error of oxygen saturation per 1 g/L decrease in blood haemoglobin. The measurement error was thus greater in those with anaemia than in those with normal haemoglobin.

Conclusion: As blood haemoglobin decreases, the oxygen saturation measurement derived from a pulse oximeter reads erroneously higher than the true value measured by ABG. While this study was confined to patients with COVID-19, physicians should be aware of this potential discrepancy among all patients with haemorrhage or known anaemia.

Background: The annual incidence of testicular torsion is approximately 1 in 4000 males under the age of 25. Despite the 97% testicular salvage rate when surgical intervention is within 6 hours of onset, orchidectomy is required in 40% of cases. These comparatively poor outcomes are driven by delays to intervention, the majority of which take place prior to presentation to healthcare. This study synthesises existing evidence to understand factors leading to delayed presentation to hospital in individuals with acute scrotal pain.

Methods: A comprehensive literature search was performed with support from an information scientist. Two authors performed article screening, data extraction and inductive thematic synthesis independently, with disagreements resolved by discussion at each stage. An assessment of confidence in the review findings was performed using the ConQual approach.

Results: The search identified 1251 unique articles for screening, with five eligible for inclusion; all included publications were drawn from two PhD projects. Synthesis of these articles revealed five descriptive themes with five subthemes. A lack of knowledge and education about testicular health, embarrassment and reliance on others for access to healthcare are major factors leading to delays in presentation. Societal and cultural impacts on health-seeking behaviour and denial were also causes of delayed presentation to healthcare.

Discussion: A lack of knowledge about testicular anatomy and health among both adults and children is amenable to improvement through education, and would likely impact many of the factors identified as contributory to delays. Communication was an overarching factor connecting the descriptive themes.

Prospero registration number: CRD42023469435.

Introduction: Stress and burnout are prevalent among emergency department (ED) staff in the UK. The concept of well-being interventions for ED staff is a growing area of interest and research worldwide. Various interventions are described in the literature, yet little is known about the experience of ED staff in the UK of interventions designed to support their well-being. This study therefore aimed to understand their experiences of these interventions.

Methods: Semi-structured interviews were carried out with nine members of staff from different professional backgrounds at a tertiary trauma centre in the UK between June and July 2023. The inclusion criteria were staff who had worked in a National Health Service ED setting in the UK for more than 12 months. Participants were asked about their experience and perceptions of well-being interventions delivered in the workplace. A phenomenographical approach was applied to analyse the narrative data.

Results: The findings resulted in seven qualitatively different but related categories. Participants experienced interventions to be: (1) necessary due to their stressful working environment; (2) beneficial in supporting their well-being; (3) feasible in an ED setting; (4) inadequate due to lack of quality and accessibility; (5) improving with increased acceptability and support; (6) restricted by clinical and organisational factors; and (7) ambiguous in definition, measurement and individual interpretation. Space for facilitated reflection and role modelling by leaders were felt to be important.

Conclusions: Job demands simultaneously necessitate and restrict the provision of adequate interventions to support well-being in the ED. These demands need to be addressed as part of wider organisational change including the provision of self-care facilities and opportunities, protected time for facilitated reflection, high-quality and accessible learning opportunities for personal and professional development, training for staff delivering well-being interventions and positive role modelling by leaders.

Background: Acute aortic syndrome (AAS) requires urgent diagnosis with computed tomographic angiography (CTA). Diagnostic strategies need to weigh the benefits of detecting AAS against the costs of using CTA with a low yield of AAS when the prevalence of AAS is low. We aimed to estimate the cost-effectiveness of diagnostic strategies using clinical probability scoring and D-dimer to select patients with potential symptoms of AAS for CTA.

Methods: We developed a decision analytical model to simulate the management of patients attending hospital with possible AAS. We modelled diagnostic strategies that used the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer to select patients for CTA. We used estimates from our meta-analysis, existing literature and clinical experts to model the consequences of diagnostic strategies on survival, health utility, and health and social care costs. We estimated the incremental cost per quality-adjusted life-years gained by each strategy compared with the next most effective alternative on the efficiency frontier.

Results: A strategy based on the Canadian guideline (CTA if ADD-RS>1 or ADD-RS=1 with D-dimer >500 ng/mL) is cost-effective but would result in high rates of CTA if applied to an unselected population (AAS prevalence 0.26%). The strategy is also cost-effective and would result in lower rates of CTA if applied to a more selected population, such as those with a non-zero clinical suspicion of AAS (prevalence 0.61%). For patients currently receiving CTA, using ADD-RS>1 or D-dimer >500 ng/mL to select patients for CTA is cost-effective.

Conclusions: A strategy using ADD-RS>1 or ADD-RS=1 with D-dimer >500 ng/mL to select patients for CTA appears cost-effective but primary research is required to evaluate this strategy in practice and determine how suspicion of AAS is identified.

Background: Patients with traumatic out-of-hospital cardiac arrest (t-OHCA) require on-scene airway management to maintain tissue oxygenation. However, the benefits of prehospital endotracheal intubation remain unclear, particularly regarding neurological outcomes. Therefore, this study aimed to evaluate the association between prehospital intubation and favourable neurological outcomes in patients with t-OHCA.

Methods: This retrospective cohort study used a Japanese nationwide trauma registry from 2019 to 2021. It included adult patients diagnosed with traumatic cardiac arrest on emergency medical service arrival. Glasgow Outcome Scale (GOS) scores, survival at discharge and presence of signs of life on hospital arrival were compared between patients with prehospital intubation and those with supraglottic airway or manual airway management. Inverse probability weighting with propensity scores was used to adjust for patient, injury, treatment and institutional characteristics, and the effects of intubation on outcomes averaged over baseline covariates were shown as marginal ORs.

Results: A total of 1524 patients were included in this study, with 370 undergoing intubation before hospital arrival. Prehospital intubation was associated with favourable neurological outcomes at discharge (GOS≥4 in 5/362 (1.4%) vs 10/1129 (0.9%); marginal OR 1.99; 95% CI 1.12 to 3.53; p=0.021) and higher survival to discharge (25/370 (6.8%) vs 63/1154 (5.5%); marginal OR 1.43; 95% CI 1.08 to 1.90; p=0.012). However, no association with signs of life on hospital arrival was observed (65/341 (19.1%) vs 147/1026 (14.3%); marginal OR 1.09; 95% CI 0.89 to 1.34). Favourable outcomes were observed only in patients who underwent intubation with a severe chest injury (Abbreviated Injury Score ≥3) and with transportation time to hospital >15 min (OR 14.44 and 2.00; 95% CI 1.89 to 110.02 and 1.09 to 3.65, respectively).

Conclusions: Prehospital intubation was associated with favourable neurological outcomes among adult patients with t-OHCA who had severe chest injury or transportation time >15 min.

Introduction: Optimising emergency department (ED) patient experience is vital to ensure care quality. However, there are few validated instruments to measure the experiences of specific patient groups, including older adults. We previously developed a draft 82-item Patient Reported Experience Measure (PREM-ED 65) for adults ≥65 attending the ED. This study aimed to derive a final item list and provide initial validation of the PREM-ED 65 survey.

Methods: A cross-sectional study involving patients in 18 EDs in England. Adults aged 65 years or over, deemed eligible for ED discharge, were recruited between May and August 2021 and asked to complete the 82-item PREM at the end of the ED visit and 7-10 days post discharge. Test-retest reliability was assessed 7-10 days following initial attendance. Analysis included descriptive statistics, including per-item proportions of responses, hierarchical item reduction, exploratory factor analysis (EFA), reliability testing and assessment of criterion validity.

Results: Five hundred and ten initial surveys and 52 retest surveys were completed. The median respondent age was 76. A similar gender mix (men 47.5% vs women 50.7%) and reason for attendance (40.3% injury vs 49.0% illness) was observed. Most participants self-reported their ethnicity as white (88.6%).Hierarchical item reduction identified 53/82 (64.6%) items for exclusion, due to inadequate engagement (n=33), ceiling effects (n=5), excessive inter-item correlation (n=12) or significant differential validity (n=3). Twenty-nine items were retained.EFA revealed 25 out of the 29 items demonstrating high factor loadings (>0.4) across four scales with an Eigenvalue >1. These scales were interpreted as measuring 'relational care', 'the ED environment', 'staying informed' and 'pain assessment'. Cronbach alpha for the scales ranged from 0.786 to 0.944, indicating good internal consistency. Test-retest reliability was adequate (intraclass correlation coefficient 0.67). Criterion validity was fair (r=0.397) when measured against the Friends and Families Test question.

Conclusions: Psychometric testing demonstrates that the 25-item PREM-ED 65 is suitable for administration to adults ≥65 years old up to 10 days following ED discharge.