SARS-CoV-2 Testing and Patient Waiting Times in the Emergency Department.

Aim Emergency Departments (EDs) were impacted early in the coronavirus disease 2019 (COVID-19) pandemic, with high attendance numbers. EDs relied upon SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR) tests to triage patients and facilitate admission to appropriate wards, meaning positive patients were isolated as early as possible. In October 2020, we introduced a 24-hour SARS-CoV-2 testing service. We examined the impact of this on patient experience times (PETs) in the ED, and on healthcare-associated (HA) COVID-19 infections. Methods Data on PETs before and after the introduction of 24-hour testing were available from the ED. HA COVID-19 infections were reported weekly to the Health Services Executive as a key performance indicator. Results Mean PET prior to the pandemic was 20 hours and dropped to 10 and 13 hours respectively in the first and second wave. A surge in case numbers and ED attendances during the third wave was not reflected in a rise in PETs, with a mean PET of 11 hours, significantly below pre-pandemic levels. HA-COVID-19 infections remained stable between wave one and three (83 v 92). Conclusion The introduction of 24-hour SARS-CoV-2 testing in our ED contributed to a reduction in PETs, facilitated appropriate patient placement at ward level, and kept HA-COVID-19 infections at acceptably low levels.

Increased number of community-living older adults attending an emergency department with falls and fractures: North Dublin experience.

BACKGROUND: The number of attendances to emergency department (ED) due to falls and fractures increases as the population ages. The community-based falls prevention strategy may reduce the number of falls requiring medical attention. AIM: Our aim was to determine the changes over time in community-living older adults on the number of attendances to an urban ED over a 5 year period. METHODS: Community-living adults aged ≥65 years from a catchment attending with falls and fractures to an ED in 2010 and 2014 were identified through an electronic patient record. The age, gender and patient-related outcome (admit, discharge with and without follow-up, died in department) were collected. Patient-related outcome was compared by age group. RESULTS: There were 477 and 772 attendances with falls and fractures in 2010 and 2014, respectively. Between 3 and 7% were repeat attendees. Compared with 2010, in 2014, there were more women attendees; the proportion of patients aged ≥80 years were higher, more likely to be admitted and discharged without follow-up. Patients aged 85+ were six times more likely to require admission compared with under 75's. CONCLUSION: With the rapidly ageing population in North Dublin, there is an urgent need to prioritise comprehensive assessment and provide a coordinated falls programme when older adults present to ED to reduce the risk of future falls and injuries.

Impact of season, weekends and bank holidays on emergency department transfers of nursing home residents.

BACKGROUND: For urgent, unexpected clinical events, nursing home (NH) residents are transferred to the acute hospital emergency department (ED). A previous study showed that a third of transfers occurred during working hours. AIMS: Our aims were to profile a one-year NH transfers to the ED and to examine the re-presentation, patient-oriented outcome and the impact of season, weekends and bank holidays on NH transfers. METHODS: All NH transfers from a catchment to an ED over one year were identified using electronic patient record. Age, gender, reason for presentation, patient-oriented outcome and date and time of presentation were recorded. Representation and the interval between transfers were calculated. Number of transfers was calculated for season, weekdays/weekends and bank holidays. Student t test, Chi-square statistics and one-way ANOVA were used. Significance was set at 0.05. RESULTS: There were 802 transfers from 465 NH residents over a year; 501 (62.5 %) resulted in admissions, 189 (40.6 %) residents represent to the service and 80 episodes occurred within a fortnight of the last attendance. The highest transfers occurred in May (2.81 patients/day), during working hours and on Wednesdays and Thursdays (>2.5 transfers/day). 'Unwell adult' and 'falls' were the two commonest reasons for presentation. CONCLUSIONS: Our study showed that NH transfers occurred mainly within working hours and during weekdays. Insights into the transfer pattern and the reasons for NH patients to utilise ED will facilitate improved design and operation of the department by creating care pathways for these patients.

Impairment of coagulation by commonly used resuscitation fluids in human volunteers.

BACKGROUND: This study compared the effects of two commonly used resuscitation fluids on whole blood coagulation. METHODS: 1000 ml of two resuscitation fluids each (saline and Gelofusine) were given to eight volunteers in a crossover design with a 2-week washout period. The effect on whole blood coagulation was assessed using the Sonoclot analyzer, a conventional coagulation screen and coagulation markers. RESULTS: No significant effect was found on whole blood coagulation by giving saline (time to peak clot increased by a mean of 106 s; (95% confidence interval (CI) -140 to 354), whereas Gelofusine delayed the time to peak by a mean of 845 s (95% CI 435 to 1255). By contrast, there was no change in the conventional coagulation screen with either fluid. CONCLUSION: It was concluded that some resuscitation fluids have an effect on clot formation that is not shown by the conventional coagulation screen, but is disclosed only if the whole coagulation process is studied.

The effects of commonly used resuscitation fluids on whole blood coagulation.

OBJECTIVES: Evidence on the effect of crystalloid and colloid resuscitation fluids on coagulation is confusing, with contradictory results from previous studies. This study was performed to test the effect on whole blood coagulation of a range of resuscitation fluids in vitro using a single method at a single dilution. METHODS: Seven resuscitation fluids were tested in vitro at a dilution of 40%. Whole blood coagulation was measured using a Sonoclot analyser. RESULTS: A crystalloid/colloid split of effect on coagulation in vitro was not seen. The time to clot formation with Gelofusine, dextran and hydroxyethyl starch was a greatly increased, whereas saline and Haemaccel had little effect, or were slightly procoagulant. CONCLUSIONS: Some resuscitation fluids have a profound effect on coagulation. The confusion in the literature may result from the effect on coagulation being both fluid and dilution dependent, with no simple crystalloid/colloid split.

Accident and emergency medicine--still a useful 'apprenticeship'?

The objective of this study was to compare the expressed confidence of senior house officers (SHOs) at performing practical medical procedures before and after working in an accident and emergency (A&E) post. The extent of formal teaching of these skills and opportunity for independent performance of them was also assessed. A postal questionnaire was sent to all SHOs completing an A&E post in the Trent region of the United Kingdom. Doctors were asked to grade their subjective confidence at performing listed practical skills before and after working in A&E. Eighty-four replies from 120 questionnaires were received (70% response rate). There was a significant improvement in confidence ( <0.0001) for all the skills studied after working in A&E. The proportion of doctors who received instruction varied for each of the skills. The expressed confidence of SHOs in performing practical procedures improved dramatically after working in A&E. Although remaining a valuable 'apprenticeship' for junior doctors, structured training is inadequate in the accident and emergency SHO post.

Sonoclot coagulation analysis of in-vitro haemodilution with resuscitation solutions.

The colloid and crystalloid solutions used for resuscitation should preferably be free from effects on coagulation. In 10 volunteers, the effects of haemodilution with various concentrations of 0.9% sodium chloride and 4% succinylated gelatin were assessed by Sonoclot analysis, which describes the whole coagulation process. Small and moderate haemodilution (up to 40%) with 0.9% sodium chloride promoted coagulation. Similar haemodilution with 4% succinylated gelatin impaired coagulation, and at 60% haemodilution coagulation was very poor. These findings need to be confirmed in vivo and their clinical relevance determined.

Fatal flecainide intoxication.

Flecainide acetate is a potent class 1C antiarrhythmic agent used mainly for the treatment of supraventricular arrhythmias. Acute overdose of this drug is rare but frequently fatal. The clinical course of a patient that ingested a large quantity of flecainide as a suicide attempt is described and current therapeutic strategies discussed.

Computed tomography of the head by the accident and emergency department--why 24 hour access is vital.

OBJECTIVE: To examine the use made of 24 hour access to computed tomography from an accident and emergency (A&E) department and to assess whether clear benefits for patients could be identified by having such a service. METHODS: Retrospective review of 176 cases where computed tomography was ordered by A&E staff of a large teaching hospital over a one year period. RESULTS: 53% of scans were done "out of hours"; 97% of scans performed (171/176) were studies of the brain. Three examinations were of the cervical spine and two were of the chest. 54% of head scans (93/171) were performed for either confirmed or suspected trauma with 46% (78/171) done for medical indications. Only 16% (11/71) of patients who had a head scan for acute trauma required transfer to the regional neurosurgical unit after consultation. Computed tomography was 100% sensitive in the diagnosis of sub-arachnoid haemorrhage. In cases where computed tomography was performed for coma of undetermined origin the pathology causing coma was identified on computed tomography in 50% of cases. CONCLUSIONS: Computed tomography facilities allow comprehensive initial evaluation of the head injured patient and minimise hazardous and expensive transfer of these seriously ill patients. Experience shows that it is a vital tool in the initial differential diagnosis of the comatose patient and therefore must be available for use by senior and middle grade A&E staff on a 24 hour basis.

"Not so immediate" hypersensitivity--the danger of biphasic anaphylactic reactions.

OBJECTIVE: To assess how commonly clinically significant biphasic anaphylactic reactions occur after apparently successful treatment of an anaphylactic reaction. Cases were analysed to determine whether there were any markers that would allow early identification of patients who would subsequently develop a biphasic response. METHOD: Retrospective review of case notes of 34 patients admitted for observation after an anaphylactic reaction that had required treatment with adrenaline. RESULTS: Six patients (18%) had biphasic reactions. No clinical features on initial presentation identified those likely to have a biphasic response. These patients however required significantly more adrenaline to ameliorate their initial symptoms (p = 0.03) compared with those having a simple uniphasic reaction. CONCLUSIONS: Biphasic anaphylactic reactions occur frequently. There are no clinical features that allow identification of patients likely to have a biphasic response. These patients require higher doses of adrenaline to control their initial symptoms and this should be considered a marker for patients who may develop a biphasic response. These results confirm that all patients being discharged after treatment for an acute anaphylactic reaction must be made aware of the risk of a second phase response after apparent clinical resolution.

Mapeamento cerebral nas epilepsias / Brain mapping in the epilepsy

O autor traça comparaçöes sobre a história do EEG convencional com a do EEG quantitativo ou digital, revisa as indicaçöes clínicas deste procedimento e mostra a sua experiência pessoal com alguns casos de mapeamento cerebral