The impact of prehospital blood sampling on the emergency department process of patients with chest pain: a pragmatic non-randomized controlled trial.

BACKGROUND: In patients with chest pain who arrive at the emergency department (ED) by ambulance, venous access is frequently established prehospital, and could be utilized to sample blood. Prehospital blood sampling may save time in the diagnostic process. In this study, the association of prehospital blood draw with blood sample arrival times, troponin turnaround times, and ED length of stay (LOS), number of blood sample mix-ups and blood sample quality were assessed. METHODS: The study was conducted from October 1, 2019 to February 29, 2020. In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome (ACS), outcomes were compared between cases, in whom prehospital blood draw was performed, and controls, in whom blood was drawn at the ED. Regression analyses were used to assess the association of prehospital blood draw with the time intervals. RESULTS: Prehospital blood draw was performed in 100 patients. In 406 patients, blood draw was performed at the ED. Prehospital blood draw was independently associated with shorter blood sample arrival times, shorter troponin turnaround times and decreased LOS (P<0.001). No differences in the number of blood sample mix-ups and quality were observed (P>0.05). CONCLUSION: For patients with acute chest pain with low suspicion for ACS, prehospital blood sampling is associated with shorter time intervals, while there were no significant differences between the two groups in the validity of the blood samples.

[Oral care in patients with ALS: an exploratory study]. / Mondverzorging bij patiënten met ALS: een verkennend onderzoek.

For this exploratory study, ALS patients and their partners/caregivers were interviewed to find out what problems they encounter when performing oral care. In addition, the tooth brushing procedure was recorded on video. Most mentioned by the six patients was that the performance of oral care is hampered by the loss of motor skills and by the gag reflex. They also mentioned various adjustments that would ease dental visits. Three of the four partners indicated that an instructional video would have additional value, and two partners said they sometimes felt insecure whether they were performing oral care properly. The five videos showed that there are major differences regarding tooth brushing duration, which surfaces are being brushed, and the brushing technique. This study shows that there are several ways in which oral care is performed in ALS patients. Furthermore, not all caregivers are aware of how oral care should be performed.

Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study.

BACKGROUND: As unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years. METHODS: Data was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs. RESULTS: Of the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category "urgent", longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%). CONCLUSION: As the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented. TRIAL REGISTRATION: For this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7th of November 2017.

Effects of process changes on emergency department crowding in a changing world: an interrupted time-series analysis.

BACKGROUND: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients' length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. METHODS: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. RESULTS: Longer patients' ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018-2019, patients' ED LOS and the number of exit blocks increased. CONCLUSIONS: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.

Increased footwear comfort is associated with improved running economy - a systematic review and meta-analysis.

Footwear with or without custom foot orthotics have the potential to improve comfort, but the link with running performance needs further investigation. We systematically reviewed the association of footwear comfort on running economy in recreational runners. Nine electronic databases were searched from inception to March 2020. Eligible studies investigated both direct outcome measures of running performance (e.g. running speed) and/or physiological measures (e.g. running economy (RE)) alongside comfort for each footwear condition tested. Methodological quality was assessed using the "Effective Public Health Practice Project" (EPHPP). RE during submaximal running was the most common physiological outcome reported in 4 of the 6 eligible studies. The absolute difference in RE between the most and least comfortable footwear condition was computed, and meta-analysis was conducted using a random effect model. The most comfortable footwear is associated with a reduction in oxygen consumption (MD: -2.06 mL.kg-1.min-1, 95%CI: -3.71, -0.42, P = 0.01) while running at a set submaximal speed. There was no significant heterogeneity (I2 = 0%, P = 0.82). EPHPP quality assessment demonstrated weak quality of the studies, due to reporting bias and failing to disclose the psychometric properties of the outcome measures. It can be concluded with moderate certainty that improved RE in recreational athletes is associated with wearing more comfortable footwear compared to less comfortable footwear.HighlightsThis systematic review reports on the association of footwear comfort with running economy in recreational runners.Running economy during constant submaximal running is likely improved in recreational runners wearing more comfortable compared to less comfortable footwear.This finding is based on a meta-analysis, including four studies, showing a small but statistically significant decreased oxygen consumption at steady state speeds while wearing the most comfortable footwear.

Association between Covid-19 surge and emergency department patient flow and experience.

BACKGROUND: Preparations for Covid-19 in the Netherlands included hospital reconfigurations to increase capacity for the expected surge at the emergency department (ED). We describe patients' ED length of stay (LOS), crowding and experiences of patients with respiratory complaints during the first Covid-19 peak. METHODS: Retrospective analysis of demand, ED LOS, crowding, and a patient experience survey during a 12-week period in 2020 and similar periods in 2018 and 2019. Crowding levels were calculated using the National ED OverCrowding Scale. RESULTS: The number of patients with respiratory complaints increased significantly, while total ED numbers were unchanged. Although presentation during the Covid-19 peak and needing hospital admission were associated with a longer ED LOS in patients with respiratory complaints, significantly less crowding occurred compared with the 2018 and 2019 periods. Increased ED LOS was associated with lower patient experience scores. CONCLUSION: Advanced warning and its associated preparation within the hospital and the community prevented significant delays in ED throughput during the first Covid-19 peak.

Impact of the COVID-19 pandemic on family carers of those with profound and multiple intellectual disabilities: perspectives from UK and Irish Non-Governmental Organisations.

BACKGROUND: Family carers of people with profound and multiple intellectual disabilities (PMID) experienced a reduction in healthcare services due to the COVID-19 pandemic. Many subsequently turned to Non-Governmental Organisations who worked to support families. However, little research has sought to capture the experiences of family carers or identify effective interventions which might support them. To address these concerns we explored the views of Non-Governmental sector workers across the UK and Ireland who supported families people with PMID during the COVID-19 pandemic. We also sought to explore their views on the characteristics of online support programmes for family carers.  METHODS: This study employed a qualitative design using focus groups with participants (n = 24) from five Non-Governmental Organisations across the UK and Ireland. A focus group guide included questions on challenges, supports, coping and resources which helped during lockdown restrictions. Focus groups were held online, were audio recorded and transcribed verbatim. The resulting transcripts were pseudonymised and subjected to thematic analysis. FINDINGS: Four themes were identified (i) 'mental and emotional health', (ii) 'they who shout the loudest' (fighting for services), (iii) 'lack of trust in statutory services' and (iv) 'creating an online support programme'. Mental and emotional health emerged as the most prominent theme and included three subthemes named as 'isolation', 'fear of COVID-19' and 'the exhaustion of caring'. CONCLUSIONS: The COVID-19 pandemic has increased the vulnerability of family carers who were already experiencing difficulties in accessing services and supports for their families. While Non-Governmental Organisations have been a crucial lifeline there is urgent need to design services, including online support programmes, in partnership with family carers which adequately address their needs.

Painful lower limb nodules as first symptom of resectable pancreatic acinar cell cancer: a case report.

BACKGROUND: Pancreatic panniculitis is characterized by subcutaneous fat necrosis and is a rare presentation of an underlying pancreatic disease, appearing in approximately 2-3% of all patients with a pancreatic disease. The nodules usually involve the lower extremities. Pancreatic panniculitis is commonly associated with acute or chronic pancreatitis, and occasionally with pancreatic cancer, especially acinar cell carcinoma. CASE PRESENTATION: A 77-year-old Caucasian woman with no significant medical history was referred to our center with multiple painful, itchy, and warm red/blue cutaneous nodules on the left lower leg. These skin lesions were consistent with the clinical diagnosis of panniculitis. The skin biopsy obtained showed a predominantly lobular panniculitis with fat necrosis of which the aspect was highly suspicious for pancreatic panniculitis. Further analysis revealed high lipase serum of > 3000 U/L (normal range < 60 U/L), and on computed tomography scan a mass located between the stomach and the left pancreas was seen. Endoscopic ultrasonography-guided fine-needle biopsy confirmed the diagnosis of acinar cell carcinoma. After discussing the patient in the pancreatobiliary multidisciplinary team meeting, laparoscopic distal pancreatectomy including splenectomy and en bloc wedge resection of the stomach due to tumor in-growth was performed. The cutaneous nodules on both legs disappeared 1-2 days after surgery. No long-term complications were reported during follow-up. One year after surgery, the patient presented with similar symptoms as preoperatively. Computed tomography scan showed local recurrence and distal metastases, which were subsequently confirmed by biopsy. She started with palliative folinic acid-fluorouracil-irinotecan-oxaliplatin chemotherapy but stopped after two cycles because of disease progression. The patient died 2 months later, 13 months after surgical resection. CONCLUSION: This case illustrates the importance of clinically recognizing cutaneous nodules and pathological recognizing the specific microscopic changes as sign of a (malignant) pancreatic disease.

Platelets after burn injury - hemostasis and beyond.

Burn injuries are common and often life-threatening trauma. With this trauma comes an interruption of normal hemostasis, with distinct impacts on platelets. Our interest in the relationships between burn injury and platelet function stems from two key perspectives: platelet function is a vital component of acute responses to injury, and furthermore the incidence of cardiovascular disease (CVD) is higher in burn survivors compared to the general population. This review explores the impact of burn injury on coagulation, platelet function, and the participation of platelets in immunopathology. Potential avenues of further research are explored, and consideration is given to what therapies may be appropriate for mediating post-burn thrombopathology.

Primary sellar melanocytoma.

PURPOSE: We present an up-to-date review of all published cases of sellar melanocytoma, a benign melanocytic neoplasm arising from melanocytes present in the leptomeninges surrounding the pituitary. METHODS: Both the Medline and Embase databases were searched for case reports or case series of patients with a sellar mass consisting of melanocytes. RESULTS: All 14 identified patients developed symptoms due to compression of the surrounding structures. Symptoms included pituitary dysfunction and visual impairment. All patients received a transsphenoidal resection as first-line treatment. The diagnosis is made on pathological examination but deciding whether a sellar melanocytic tumor is best classified as a melanocytoma or a melanoma is not straightforward. DISCUSSION: Genetic analyses can help differentiate between central nervous system origin and metastasis of a cutaneous melanoma with the presence of a GNAQ and GNA11 mutations or a BRAF mutation, respectively. First choice treatment is complete resection, and in case of incomplete resection or recurrence additional radiotherapy is advised.

Telephone follow-up to reduce unplanned hospital returns for older emergency department patients: A randomized trial.

BACKGROUND/OBJECTIVES: Telephone follow-up calls could optimize the transition from the emergency department (ED) to home for older patients. However, the effects on hospital return rates are not clear. We investigated whether telephone follow-up reduces unplanned hospitalizations and/or unplanned ED return visits within 30 days of ED discharge. DESIGN: Pragmatic randomized controlled trial with allocation by month; odd months intervention group, even months control group. SETTING: Two ED locations of a non-academic teaching hospital in The Netherlands. PARTICIPANTS: Community-dwelling adults aged ≥70 years, discharged home from the ED were randomized to the intervention group (N = 4732) or control group (N = 5104). INTERVENTION: Intervention group patients: semi-scripted telephone call from an ED nurse within 24 h after discharge to identify post-discharge problems and review discharge instructions. Control group patients: scripted satisfaction survey telephone call. MEASUREMENTS: Primary outcome: total number of unplanned hospitalizations and/or ED return visits within 30 days of ED discharge. SECONDARY OUTCOMES: separate numbers of unplanned hospitalizations and ED return visits. Subgroup analysis by age, sex, living condition, and degree of crowding in the ED at discharge. RESULTS: Overall, 42% were males, and median age was 78 years. In the intervention group, 1516 of 4732 patients (32%) consented, and in the control group 1659 of 5104 (33%) patients. Unplanned 30-day hospitalization and/or ED return visit was found in 16% of intervention group patients and 14% of control group patients (odds ratio 1.16; 95% confidence interval: 0.96-1.42). Also, no statistically significant differences were found in secondary outcome measures. Within the subgroups, the intervention did not have beneficial effects for the intervention group. CONCLUSION: Telephone follow-up after ED discharge in older patients did not result in reduction of unplanned hospital admissions and/or ED return visits within 30 days. These results raise the question of whether other outcomes could be improved by post-discharge ED telephone follow-up.

Impact of ongoing centralization of acute stroke care from "drip and ship" into "direct-to-mothership" model in a Dutch urban area.

When acute stroke care is organised using a "drip-and-ship" model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the "direct-to-mothership" model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from "drip and ship" into "direct-to-mothership". Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department.

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients. Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results. Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination. Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.

Documentation of Procedural Sedation by Emergency Physicians.

INTRODUCTION: Patients presenting to the emergency department (ED) frequently require procedural sedation and analgesia (PSA) to facilitate procedures, such as joint reduction. Proper documentation of screening demonstrates awareness of the necessity of presedation assessment. It is unknown if introducing emergency physicians (EPs) at the ED improves presedation assessment and documentation. In this study the differences in documentation of ED sedation and success rates for reduction of hip dislocations in the presence versus absence of EPs are described. METHODS: In this retrospective descriptive study, we analyzed data of patients presenting with a dislocated hip post total hip arthroplasty (THA) shortly after the introduction of EPs. The primary outcome measure was the presence of documentation of presedation assessment. Secondary outcomes were documentation of medication, vital signs, and success rate of hip reductions. RESULTS: In the two-year study period, 133 sedations for hip reductions were performed. Sixty-eight sedations were completed by an EP. The documentation of fasting status, airway screening, analgesia use, and vital signs was documented significantly more often when an EP was present (respectively 64.9%, 80.3%, 37.4%, and 72.7%, all P < 0.001). There was no difference in success rate of hip reductions between the groups. CONCLUSION: PSA in the ED is associated with superior documentation of presedation assessment, medication, and vital signs when EPs are involved.

The effect of a telephone follow-up call for older patients, discharged home from the emergency department on health-related outcomes: a systematic review of controlled studies.

BACKGROUND: Older patients discharged from the emergency department (ED) are at increased risk for adverse outcomes. Transitional care programs offer close surveillance after discharge, but are costly. Telephone follow-up (TFU) may be a low-cost and feasible alternative for transitional care programs, but its effects on health-related outcomes are not clear. AIM: We systematically reviewed the literature to evaluate the effects of TFU by health care professionals after ED discharge to an unassisted living environment on health-related outcomes in older patients compared to controls. METHODS: We conducted a multiple electronic database search up until December 2019 for controlled studies examining the effects of TFU by health care professionals for patients aged ≥65 years, discharged to an unassisted living environment from a hospital ED. Two reviewers independently assessed eligibility and risk of bias. RESULTS: Of the 748 citations, two randomized controlled trials (including a total of 2120 patients) met review selection criteria. In both studies, intervention group patients received a scripted telephone intervention from a trained nurse and control patients received a patient satisfaction survey telephone call or usual care. No demonstrable benefits of TFU were found on ED return visits, hospitalization, acquisition of prescribed medication, and compliance with follow-up appointments. However, many eligible patients were not included, because they were not reached or refused to participate. CONCLUSIONS: No benefits of a scripted TFU call from a nurse were found on health services utilization and discharge plan adherence by older patients after ED discharge. As the number of high-quality studies was limited, more research is needed to determine the effect and feasibility of TFU in different older populations. PROSPERO registration number CRD42019141403.

Lean-driven interventions, including a dedicated radiologist, improve diagnostic imaging turnaround time and radiology report time at the emergency department.

PURPOSE: Emergency departments (EDs) worldwide face crowding, which negatively affects patient care. Diagnostic imaging plays a major role in management of ED patients and contributes to patients' length of stay at the ED. In this study, the impact of Lean-driven interventions on the imaging process at the ED was assessed. METHODS: During a 6-month multimodal intervention period, Lean-driven interventions and a dedicated radiologist present at the ED were implemented during peak hours (12 a.m.-8 p.m.). Data concerning patient population, radiology department turnaround time (RDTT), radiology report time (RRT), and examination time (ET) for ED patients were compared with a control period of 6 months 1 year earlier. RESULTS: RDTT, RRT, and ET were significantly shorter in the intervention period compared with those in the control period. Median RDTT was respectively 36 min (interquartile range (IQR) 24-56) and 70 min (IQR 39-127), RRT 11 min (IQR 6-21) and 37 min (IQR 15-88), and ET 22 min (IQR 14-35) and 23 min (14-38). CONCLUSION: Lean-driven interventions on the imaging process at the ED significantly reduced RDTT, RRT, and ET.

Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are typically transmitted via respiratory droplets, are leading causes of invasive diseases, including bacteraemic pneumonia and meningitis, and of secondary infections subsequent to post-viral respiratory disease. The aim of this study was to investigate the incidence of invasive disease due to these pathogens during the early months of the COVID-19 pandemic. Methods In this prospective analysis of surveillance data, laboratories in 26 countries and territories across six continents submitted data on cases of invasive disease due to S pneumoniae, H influenzae, and N meningitidis from Jan 1, 2018, to May, 31, 2020, as part of the Invasive Respiratory Infection Surveillance (IRIS) Initiative. Numbers of weekly cases in 2020 were compared with corresponding data for 2018 and 2019. Data for invasive disease due to Streptococcus agalactiae, a non-respiratory pathogen, were collected from nine laboratories for comparison. The stringency of COVID-19 containment measures was quantified using the Oxford COVID-19 Government Response Tracker. Changes in population movements were assessed using Google COVID-19 Community Mobility Reports. Interrupted time-series modelling quantified changes in the incidence of invasive disease due to S pneumoniae, H influenzae, and N meningitidis in 2020 relative to when containment measures were imposed. Findings 27 laboratories from 26 countries and territories submitted data to the IRIS Initiative for S pneumoniae (62 434 total cases), 24 laboratories from 24 countries submitted data for H influenzae (7796 total cases), and 21 laboratories from 21 countries submitted data for N meningitidis (5877 total cases). All countries and territories had experienced a significant and sustained reduction in invasive diseases due to S pneumoniae, H influenzae, and N meningitidis in early 2020 (Jan 1 to May 31, 2020), coinciding with the introduction of COVID-19 containment measures in each country. By contrast, no significant changes in the incidence of invasive S agalactiae infections were observed. Similar trends were observed across most countries and territories despite differing stringency in COVID-19 control policies. The incidence of reported S pneumoniae infections decreased by 68% at 4 weeks (incidence rate ratio 0·32 [95% CI 0·27­0·37]) and 82% at 8 weeks (0·18 [0·14­0·23]) following the week in which significant changes in population movements were recorded. Interpretation The introduction of COVID-19 containment policies and public information campaigns likely reduced transmission of S pneumoniae, H influenzae, and N meningitidis, leading to a significant reduction in life-threatening invasive diseases in many countries worldwide. Funding Wellcome Trust (UK), Robert Koch Institute (Germany), Federal Ministry of Health (Germany), Pfizer, Merck, Health Protection Surveillance Centre (Ireland), SpID-Net project (Ireland), European Centre for Disease Prevention and Control (European Union), Horizon 2020 (European Commission), Ministry of Health (Poland), National Programme of Antibiotic Protection (Poland), Ministry of Science and Higher Education (Poland), Agencia de Salut Pública de Catalunya (Spain), Sant Joan de Deu Foundation (Spain), Knut and Alice Wallenberg Foundation (Sweden), Swedish Research Council (Sweden), Region Stockholm (Sweden), Federal Office of Public Health of Switzerland (Switzerland), and French Public Health Agency (France).