Emergency Medicine Journal最新文献

Background and aim: The passage of kidney stones through the ureter creates renal colic, a severe visceral abdominal pain. Renal colic is typically managed with non-steroidal anti-inflammatory drugs and opioids. Yet, these treatments often fail to provide adequate pain relief. The erector spinae plane block (ESPB) has emerged as a potential alternative treatment. This systematic review summarises the current body of evidence on the efficacy and safety of ESPB for renal colic in the ED.

Methods: A systematic review and meta-analysis of randomised controlled trials (RCTs) and case series of ESPB in ED patients were conducted. PubMed, EMBASE, Web of Science and ClinicalTrial.gov databases were electronically searched up to 10 June 2024, for studies that compared ESPB with standard care or placebo. The Cochrane risk of bias-2 tool was used to assess the risk of bias of included studies. Meta-analysis using a random effects model was performed if two or more studies reported the same outcome. The Grading of Recommendations Assessment, Development, and Evaluation tool was used to assess the certainty of the evidence.

Results: Four studies were included, including two RCTs and two case series. A total of 53 patients received an ESPB, compared with 40 patients who received standard care. All studies were rated as having a high overall risk of bias. Meta-analysis showed a large and significant effect of ESPB on pain reduction after 30 min (standardised mean difference (SMD) -1.41 95% CI -1.90 to -0.91) and after 60 min (SMD -1.94 95% CI -3.36 to -0.52), however the level of evidence was downgraded to very low certainty due to substantial heterogeneity (I²=85%), serious concerns of bias and large imprecision. Heterogeneity in other outcome measurements precluded meta-analysis.

Conclusions: Although statistically significant, there is a low certainty regarding the positive effect of ESPB on pain reduction for renal colic in the ED. High-quality RCTs focusing on patient-reported outcomes are needed to establish the merit of ESPB for this indication.

Prospero registration number: CRD42024554077.

Background: Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown.

Aim: To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED.

Methods: The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients' allocation determined by that of attending paramedics.Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness.

Results: From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score >3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI -0.0371, 0.0183), p=0.475.

Conclusion: The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended.

Trial registration number: ISRCTN85516498.

Background: Attempting to improve emergency care (EC) advanced clinical practitioner (ACP) training, Health Education England (HEE) South West (SW) implemented a pilot, whereby emergency departments (ED) were provided with enhanced funding and support to help ED consultants deliver teaching and supervision to EC ACPs to ensure more timely completion of EC ACP training compared with previous cohorts training in the region.We explored the experiences of trainee EC ACPs and consultant EC ACP leads working in EDs, which had implemented the new regional pilot.

Methods: We used a qualitative design to conduct semi-structured interviews with trainee EC ACPs and consultant EC ACP leads across five EDs that had implemented the HEE SW pilot. Interview data were analysed thematically.

Results: Twenty-five people were interviewed. We identified four themes: (1) the master's in advanced practice could be better aligned with the Royal College of Emergency Medicine credentialling e-portfolio; (2) EC ACP training needs some flexibility to reflect the individual-'one size does not fit all'; (3) supervision and teaching were recognised as important but requires significant staff capacity that is impacted by external pressures and (4) unclear role expectations and responsibilities hinder role transition and impact role identity.It was notable that EC ACPs primarily spoke about the development of their clinical skills both academically and within the workplace, despite there being other skills mentioned in the multiprofessional framework for advanced practice (leadership and management, education and research).

Conclusion: A clear supervision structure with protected time allocated for teaching and assessment of clinical skills within the ED is essential to facilitate trainee EC ACP progression. However, increasing demands on EDs make this a challenging goal to achieve. Role identity issues continue to persist despite the introduction of new guidance designed to provide more clarity around the ACP role.

Background: The WHO recognises patient safety as a serious public health problem. The COVID-19 pandemic affected adult EDs (AEDs) and paediatric EDs (PEDs) differently. We compared the culture of safety in the adult AED and PED before and after the COVID-19 pandemic.

Methods: A quasi-experimental study was performed. In 2019, we conducted a survey using the Spanish-adapted Hospital Survey on Patient Safety Culture open to all staff (doctors, nurses and paediatric residents) in AED and PED. This survey provides scores for 12 separate domains and a global assessment of safety (scale 0-10). The survey was repeated in 2021 after the first wave of the COVID-19 pandemic. After the second survey, the researchers constructed a Pareto Chart (based on the responses from the surveys), demonstrating the most important problems to develop improvement proposals.

Results: The 2019 questionnaire was completed by 125 AED workers and 65 PED workers. The 2021 questionnaire was completed by 79 AED workers and 50 PED workers. The global assessment of safety in the AED was 6.13 points at baseline and increased to 7.58 points (p<0.001) after COVID-19. The global assessment for the PED was 6.8 points at baseline and increased to 7.62 points after COVID-19 (p<0.001). In both services, the dimension that was most favourably assessed was 'Teamwork in the Service' while 'Provision of Staff' was least favourably assessed. The Pareto charts showed four dimensions contributing more than 50% of negative responses: 'Provision of staff' and 'Hospital Management support for patient safety' coincided in both services.

Conclusion: The baseline perception of the culture of safety was higher in the PED but improved in both services during the COVID-19 pandemic. Adverse situations can provide an opportunity to improve patient safety culture.

Background: Because of their young age and lack of known comorbidities, paediatric patients with out-of-hospital cardiac arrest (OHCA) often undergo prolonged cardiopulmonary resuscitation (CPR). We aimed to determine the association between prehospital and in-hospital CPR duration and neurological outcomes.

Methods: We conducted a retrospective analysis of data from the Japanese Association for Acute Medicine-OHCA Registry for patients <18 years of age with OHCA between June 2014 and December 2019. All patients received prehospital CPR by emergency medical service (EMS). The aetiologies of arrest included traumatic and atraumatic causes. The primary outcome measure was a 1-month neurological outcome of moderate disability or better (Pediatric Cerebral Performance Category 1-3). We calculated the dynamic probability and cumulative proportion of 1-month moderate disability or better neurological outcomes. Dynamic probability calculates patient outcomes during CPR per min. We performed multivariate logistic regression analysis to explore the association between longer CPR duration (as an ordinal variable) and 1-month poorer neurological outcomes.

Results: Among 1007 eligible children, 252 achieved return of spontaneous circulation and 53 had a 1-month moderate disability or better neurological outcome. The dynamic probability of a 1-month moderate disability or better neurological outcome dropped below 0.01 at 64 min (0.005, 95% CI 0.001 to 0.017). The cumulative proportion of a 1-month moderate disability or better neurological outcome exceeded 0.99 at 68 min (1, 95% CI 1 to 1). With increasing CPR time from CPR initiation by EMS, both crude and adjusted ORs for 1-month neurological outcomes gradually decreased.

Conclusion: Using a large Japanese database of paediatric OHCA patients, we found that longer CPR duration was associated with a lower likelihood of a 1-month moderate disability or better neurological outcome. Less than 1% of paediatric patients exhibited 1-month moderate disability or better neurological outcomes when total CPR duration is more than 64 min.

Background: Despite pronounced increases in homelessness and mental health problems in the USA over the past decade, further exacerbated during the pandemic, and the higher prevalence of mental health conditions among individuals experiencing homelessness, no study has examined trends in self-injury-related ED visits by individuals experiencing homelessness using up-to-date nationwide data. To address this gap, we aimed to investigate the association of self-injury-related ED visits with homelessness and to examine trends in these ED visits by individuals experiencing homelessness.

Methods: We conducted a retrospective secondary data analysis using a nationally representative sample of ED visits by adults aged 25-64 years in the USA from the 2016-2021 National Hospital Ambulatory Medical Care Survey. We examined whether intentional self-injury-related ED visits and hospitalisations resulting from an ED visit were associated with homeless status using survey-weighted multivariable generalised linear regression models and whether trends in such visits changed over the study period.

Results: Our analysis covered 419.4 million ED visits from 2016 to 2021. Individuals experiencing homelessness constituted 1.8% (7.4 million) of ED visits. Overall, 1.8% of ED visits (7.7 million) were related to intentional self-injuries. Nearly 1 in every 10 ED visits (9.6%) by individuals experiencing homelessness were related to self-injuries, compared with 1.7% among housed counterparts (p<0.001). The adjusted incidence rate ratio for self-injury-related ED visits was 3.14 (95% CI 2.05 to 4.83) for individuals experiencing homelessness compared with housed individuals. Finally, individuals experiencing homelessness accounted for 12.0% and 11.7% of self-injury-related ED visits in 2020 and 2021, respectively (pandemic years), compared with an average of 8.4% in the previous years.

Conclusion: Among adults aged 25-64 years, experiencing homelessness was significantly associated with self-injury-related ED visits, and an increase in the rate of such visits among individuals experiencing homelessness was observed during 2020 and 2021. Future studies should assess longer-term trends in these visits and explore interventions to address the societal, health and mental healthcare needs in order to improve the health outcomes of these marginalised individuals.

Background: The role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical outcomes of emergency tracheal intubation.

Methods: We searched the PubMed, Embase, Scopus and Cochrane databases up to 5 September 2024. Randomised controlled trials comparing video laryngoscopy with direct laryngoscopy for emergency tracheal intubation were analysed. The primary outcome was the first-attempt success rate, while secondary outcomes included intubation time, glottic visualisation, in-hospital mortality and complications.

Results: Twenty-six studies (6 in prehospital settings and 20 in hospital settings) involving 5952 patients were analysed in this study. Fifteen studies had low risk of bias. Overall, there was no significant difference in first-attempt success rate between two groups (RR 1.05, 95% CI 0.97 to 1.13, p=0.24, I²=89%). However, video laryngoscopy was associated with a higher first-attempt success rate in hospital settings (emergency department: RR 1.13, 95% CI 1.03 to 1.23, p=0.007, I²=85%; intensive care unit: RR 1.16, 95% CI 1.05 to 1.29, p=0.003, I²=68%) and among inexperienced operators (RR 1.15, 95% CI 1.03 to 1.28, p=0.01, I²=72%). Conversely, the first-attempt success rate with video laryngoscopy was lower in prehospital settings (RR 0.75, 95% CI 0.57 to 0.99, p=0.04, I²=95%). There were no differences for other outcomes except for better glottic visualisation (RR 1.11, 95% CI 1.03 to 1.20, p=0.005, I²=91%) and a lower incidence of oesophageal intubation (RR 0.42, 95% CI 0.24 to 0.71, p=0.001, I²=0%) when using video laryngoscopy.

Conclusions: In hospital settings, video laryngoscopy improved first-attempt success rate of emergency intubation, provided superior glottic visualisation and reduced incidence of oesophageal intubation in critically ill patients. Our findings support the routine use of video laryngoscopy in the emergency department and intensive care units.

Prospero registration number: CRD 42023461887.