European Journal of Emergency Medicine最新文献

Recognizing and prioritizing research areas in emergency care is crucial for generating evidence and advancing research programs, aiming to enhance health outcomes for both individuals and populations. The objective of this review is to document global clinical and nonclinical research priorities. The Emergency Medicine Education and Research by Global Experts network, consisting of 22 sites across six continents, conducted a mapping review of publications on emergency medicine research priorities (2000-2022) across seven databases. We included studies with replicable methodologies for determining research priorities, excluding those limited to individual diseases. Three reviewers independently screened, selected, and categorized results into clinical and nonclinical topics. Discrepancies were resolved by an independent investigator and consensus. Outcomes measures and analysis include descriptive analysis of research priorities grouped into clinical and nonclinical topics, characteristics of publications including countries represented in the author list, target audience (such as researchers or policy makers), participants (e.g. patients), and methods (e.g. Delphi) of priority setting. Among 968 screened papers, 57 publications from all WHO regions were included. Most (36, 63%) had authors from only a single country, primarily in North America and Europe. Patient representatives were included in only 10 (18%). Clinical research priorities clustered into resuscitation, cardiology, central nervous system, emergency medical services, infectious disease, mental health, respiratory disease, and trauma. Distribution was broad in North America and Europe but focused on infectious diseases and resuscitation in Africa and Asia. Eleven nonclinical topics included access to care, health policy, screening/triage, social determinants of health, staffing, technology/simulation, shared decision making, cross-sectoral collaboration, education, patient-centered care, and research networks. Nonclinical topics were broad in Europe and America, focused on access to care and health screening in Africa, and mostly absent in other WHO regions. Published research priorities in emergency medicine are heterogeneous and geographically limited, mostly containing groups of authors from the same country. The majority of publications in global research priority setting stem from Western countries, covering a broad spectrum of clinical and nonclinical topics. Research priorities from Africa and Asia tend to focus on specific issues more prevalent in those regions of the world.

Background: The assessment of technical and nontechnical skills in emergency medicine requires reliable and usable tools. Three Acute Care Assessment Tools (ACATs) have been developed to assess medical learners in their management of cardiac arrest (ACAT-CA), coma (ACAT-coma) and acute respiratory failure (ACAT-ARF).

Objective: This study aims to analyze the reliability and usability of the three ACATs when used for in situ (bedside) simulation.

Methods: This prospective multicenter validation study tested ACATs using interprofessional in situ simulations in seven emergency departments and invited training residents to participate in them. Each session was rated by two independent raters using ACAT. Intraclass correlation coefficients (ICC) were used to assess interrater reliability, and Cronbach's alpha coefficient was used to assess internal consistency for each ACAT. The correlation between ACATs' scores and the learners' level of performance was also assessed. Finally, a questionnaire and two focus groups were used to assess the usability of the ACATs.

Results: A total of 104 in situ simulation sessions, including 85 residents, were evaluated by 37 raters. The ICC for ACAT-CA, ACAT-coma and ACAT-ARF were 0.95 [95% confidence interval (CI), 0.93-0.98], 0.89 (95% CI, 0.77-0.95) and 0.92 (95%CI 0.83-0.96), respectively. The Cronbach's alphas were 0.79, 0.80 and 0.73, respectively. The ACAT-CA and ARF showed good construct validity, as third-year residents obtained significantly higher scores than first-year residents ( P  < 0.001; P  < 0.019). The raters supported the usability of the tools, even though they expressed concerns regarding the use of simulations in a summative way.

Conclusion: This study reported that the three ACATs showed good external validity and usability.

Background and importance: Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics.

Objectives: First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history.

Design: A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases.

Setting and participants: One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated.

Outcome measures and analysis: Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests.

Main results: Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder.

Conclusion: Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Background: Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain.

Objective: To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure.

Design, settings and participants: Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability.

Intervention: Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation.

Outcomes measure: The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality.

Main results: Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P  = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P  = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates.

Conclusion: In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen.

Trial registration: NCT04971213 ( https://clinicaltrials.gov ).