Hospital referral of detainees during police custody in Amsterdam, The Netherlands.

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks.

Clinical value of drugs of abuse point of care testing in an emergency department setting.

OBJECTIVE: Toxicology screening tests for drugs-of-abuse and therapeutic drugs in urine (TST-U) are often used to assess whether a patient's clinical condition can be explained by the use of drugs-of-abuse (DOA) and/or therapeutic drugs. TST-U have clinical value when they support clinical decision making by influencing diagnosis and patient care. We aim to quantify the influence of TST-U results on diagnosis and patient care in an emergency department. Our secondary objective is to identify specific patients for which a TST-U is most warranted or mostly unhelpful. METHODS: This prospective observational study was performed at the emergency department of a middle-sized urban teaching hospital. A point of care TST-U has been used in this department for three years. When a TST-U is considered indicated by a physician, the influence of the TST-U result on diagnosis and patient care is quantified before and after the test results are available, by means of a questionnaire. Urgency and complaints upon admission have also been registered. RESULTS: Of 100 TST-U results 37% were reported having a substantial influence on diagnosis and 25% on patient care. TST-U had a substantial influence on diagnosis in 48% of patients with decreased consciousness, 47% of patients with psychiatric symptoms and in 47% of patients with "other" complaints. In this last category patients with neurological symptoms benefited most. In patients who were already suspected to be intoxicated, only 18% of the TST-U results had substantial influence on diagnosis. CONCLUSIONS: The use of point of care TST-U in an Emergency Department helps physicians to understand the clinical condition of a patient. They influence the way a patient is treated to a lesser extent. These tests are most helpful in patients with decreased consciousness, psychiatric or neurological symptoms and mostly unhelpful in patients who, upon admission, are already known to be intoxicated.

Procedural sedation and analgesia in children by non-anesthesiologists in an emergency department.

Procedural sedation and analgesia (PSA) is a standard of care for the management of acute procedural pain and anxiety in the emergency department (ED). However, there is evidence that PSA practice is still ineffective and potentially unsafe in many pediatric settings. PSA has to be regarded as a separate medical act that should be provided only by well-trained and credentialized professionals, within a context of transparency, registration and ongoing quality control. Only by maintaining strict criteria regarding professional competences, safety precautions, monitoring, recovery and rescue facilities an optimal patient safety can be guaranteed. Besides, ED professionals have a duty to deliver effective PSA, not only from a procedural point of view (i.e. guaranteeing predictable procedural success and timing) but also from a patient's perspective (i.e. achieving optimal procedural comfort). An effective PSA program on a pediatric ED means that a professional is easily available at all times who is trained in the safe use of highly controllable drugs that match the sedation need and guarantee an optimal level of comfort without the need for forced immobilization or restraint. A high-quality PSA service includes the adequate use of local or topical anesthesia, the systematic application of non-pharmacologic techniques, the availability of effective PSA drugs and the possibility of rescue anesthesia in case PSA is unsuccessful or is expected to be ineffective or unsafe in a given patient. PSA for children, including deep sedation, should be formally incorporated in the training program for emergency physicians.