Management of syncope in the Emergency Department: a European prospective cohort study (SEED).

BACKGROUND AND IMPORTANCE: In 2018, the European Society of Cardiology (ESC) produced syncope guidelines that for the first-time incorporated Emergency Department (ED) management. However, very little is known about the characteristics and management of this patient group across Europe. OBJECTIVES: To examine the prevalence, clinical presentation, assessment, investigation (ECG and laboratory testing), management and ESC and Canadian Syncope Risk Score (CSRS) categories of adult European ED patients presenting with transient loss of consciousness (TLOC, undifferentiated or suspected syncope). DESIGN: Prospective, multicentre, observational cohort study. SETTINGS AND PARTICIPANTS: Adults (≥18 years) presenting to European EDs with TLOC, either undifferentiated or thought to be of syncopal origin. MAIN RESULTS: Between 00:01 Monday, September 12th to 23:59 Sunday 25 September 2022, 952 patients presenting to 41 EDs in 14 European countries were enrolled from 98 301 ED presentations (n = 40 sites). Mean age (SD) was 60.7 (21.7) years and 487 participants were male (51.2%). In total, 379 (39.8%) were admitted to hospital and 573 (60.2%) were discharged. 271 (28.5%) were admitted to an observation unit first with 143 (52.8%) of these being admitted from this. 717 (75.3%) participants were high-risk according to ESC guidelines (and not suitable for discharge from ED) and 235 (24.7%) were low risk. Admission rate increased with increasing ESC high-risk factors; 1 ESC high-risk factor; n = 259 (27.2%, admission rate=34.7%), 2; 189 (19.9%; 38.6%), 3; 106 (11.1%, 54.7%, 4; 62 (6.5%, 60.4%), 5; 48 (5.0%, 67.9%, 6+; 53 (5.6%, 67.9%). Furthermore, 660 (69.3%), 250 (26.3%), 34 (3.5%) and 8 (0.8%) participants had a low, medium, high, and very high CSRS respectively with respective admission rates of 31.4%, 56.0%, 76.5% and 75.0%. Admission rates (19.3-88.9%), use of an observation/decision unit (0-100%), and percentage high-risk (64.8-88.9%) varies widely between countries. CONCLUSION: This European prospective cohort study reported a 1% prevalence of syncope in the ED. 4 in 10 patients are admitted to hospital although there is wide variation between country in syncope management. Three-quarters of patients have ESC high-risk characteristics with admission percentage rising with increasing ESC high-risk factors.

Burnout in emergency medicine professionals after 2 years of the COVID-19 pandemic: a threat to the healthcare system?

BACKGROUND: Burnout is a common problem among healthcare professionals (HCPs), in particular young doctors and nurses working in emergency medical services. The coronavirus disease 2019 (COVID-19) pandemic has generated a substantial increase in the workload of those working in front-line services, and there is evidence of physical and mental distress among professionals that may have caused an increase in burnout. OBJECTIVE: The objective of the study was to evaluate the level of burnout in the different professionals of emergency medical services. DESIGN AND PARTICIPANTS: In January and February 2022, we conducted an online survey based on the Abbreviate Maslach inventory with the addition of three questions focused on possible modifying factors. The survey was disseminated to HCP via the list of European Society for Emergency Medicine contacts. OUTCOME MEASURES: The analysis was based on two of the three elements of the Maslach burnout concept, 'depersonalisation', 'emotional exhaustion', and 'personal accomplishment'. Overall burnout was defined when at least one of the two elements 'depersonalisation' or 'emotional exhaustion' reached the level of high burnout. RESULTS: The number of responders was 1925, 84% of which were physicians, 12% nurses, and 2% paramedics. Burnout was present in 62% of all responders. A high burnout level was reported for depersonalisation, emotional exhaustion, and personal accomplishment in 47%, 46%, and 48% of responders, respectively. Females reported a higher proportion of burnout compared with males 64% vs. 59%, difference -6% [95% confidence interval CI, -8 to -1.9], and nurses higher than physicians, 73% vs. 60%, difference -13 (95% CI, -18.8 to -6). Less experienced professionals reported higher levels of burnout: those with less than 5 years of experience the burnout level was 74% compared with the group with more than 10 years, 60%, difference -26% (95% CI, -32 to -19.5). Reported frequent understaffing situations were associated with a higher risk of burnout: 70% vs. 37%, difference -33% (95% CI, -41 to -25). Burnout was associated with a higher risk of desire to change the workplace: 87% vs. 40%, difference -47% (95% CI, -52 to -42). Survey responders reported having access to support programmes in 41% of cases. CONCLUSION: In this study, there is a high reported level of burnout among emergency HCPs. Several risk factors were identified such as being understaffed, female, or having less experience. HCPs with burnout thought more frequently about leaving the workplace, posing a threat to healthcare systems.

Meeting the International Health Regulations (2005) surveillance core capacity requirements at the subnational level in Europe: the added value of syndromic surveillance.

BACKGROUND: The revised World Health Organization's International Health Regulations (2005) request a timely and all-hazard approach towards surveillance, especially at the subnational level. We discuss three questions of syndromic surveillance application in the European context for assessing public health emergencies of international concern: (i) can syndromic surveillance support countries, especially the subnational level, to meet the International Health Regulations (2005) core surveillance capacity requirements, (ii) are European syndromic surveillance systems comparable to enable cross-border surveillance, and (iii) at which administrative level should syndromic surveillance best be applied? DISCUSSION: Despite the ongoing criticism on the usefulness of syndromic surveillance which is related to its clinically nonspecific output, we demonstrate that it was a suitable supplement for timely assessment of the impact of three different public health emergencies affecting Europe. Subnational syndromic surveillance analysis in some cases proved to be of advantage for detecting an event earlier compared to national level analysis. However, in many cases, syndromic surveillance did not detect local events with only a small number of cases. The European Commission envisions comparability of surveillance output to enable cross-border surveillance. Evaluated against European infectious disease case definitions, syndromic surveillance can contribute to identify cases that might fulfil the clinical case definition but the approach is too unspecific to comply to complete clinical definitions. Syndromic surveillance results still seem feasible for comparable cross-border surveillance as similarly defined syndromes are analysed. We suggest a new model of implementing syndromic surveillance at the subnational level. In this model, syndromic surveillance systems are fine-tuned to their local context and integrated into the existing subnational surveillance and reporting structure. By enhancing population coverage, events covering several jurisdictions can be identified at higher levels. However, the setup of decentralised and locally adjusted syndromic surveillance systems is more complex compared to the setup of one national or local system. SUMMARY: We conclude that syndromic surveillance if implemented with large population coverage at the subnational level can help detect and assess the local and regional effect of different types of public health emergencies in a timely manner as required by the International Health Regulations (2005).

Non-infectious events under the International Health Regulations (2005) in Europe--a case for syndromic surveillance.

The scope of the International Health Regulations of 2005 (IHR (2005)) has been expanded. The IHR (2005) are no longer limited to a specific set of infectious diseases, instead they prescribe detection and assessment of any event of potential public health concern regardless of its source or origin. We examine events of non-infectious origin that might fulfill the criteria of a potential public health emergency of international concern under the IHR (2005). These comprise predominately events related to food safety, but also events related to drug safety or of chemical or industrial origin. We argue that to identify these events and assess health effects related to them, existing disease surveillance systems should be augmented with less specific indicator-based syndromic surveillance strategies that use available routine health-related service data for monitoring purposes.

Validity and timeliness of syndromic influenza surveillance during the autumn/winter wave of A (H1N1) influenza 2009: results of emergency medical dispatch, ambulance and emergency department data from three European regions.

BACKGROUND: Emergency medical service (EMS) data, particularly from the emergency department (ED), is a common source of information for syndromic surveillance. However, the entire EMS chain, consists of both out-of-hospital and in-hospital services. Differences in validity and timeliness across these data sources so far have not been studied. Neither have the differences in validity and timeliness of this data from different European countries. In this paper we examine the validity and timeliness of the entire chain of EMS data sources from three European regions for common syndromic influenza surveillance during the A(H1N1) influenza pandemic in 2009. METHODS: We gathered local, regional, or national information on influenza-like illness (ILI) or respiratory syndrome from an Austrian Emergency Medical Dispatch Service (EMD-AT), an Austrian and Belgian ambulance services (EP-AT, EP-BE) and from a Belgian and Spanish emergency department (ED-BE, ED-ES). We examined the timeliness of the EMS data in identifying the beginning of the autumn/winter wave of pandemic A(H1N1) influenza as compared to the reference data. Additionally, we determined the sensitivity and specificity of an aberration detection algorithm (Poisson CUSUM) in EMS data sources for detecting the autumn/winter wave of the A(H1N1) influenza pandemic. RESULTS: The ED-ES data demonstrated the most favourable validity, followed by the ED-BE data. The beginning of the autumn/winter wave of pandemic A(H1N1) influenza was identified eight days in advance in ED-BE data. The EP data performed stronger in data sets for large catchment areas (EP-BE) and identified the beginning of the autumn/winter wave almost at the same time as the reference data (time lag +2 days). EMD data exhibited timely identification of the autumn/winter wave of A(H1N1) but demonstrated weak validity measures. CONCLUSIONS: In this study ED data exhibited the most favourable performance in terms of validity and timeliness for syndromic influenza surveillance, along with EP data for large catchment areas. For the other data sources performance assessment delivered no clear results. The study shows that routinely collected data from EMS providers can augment and enhance public health surveillance of influenza by providing information during health crises in which such information must be both timely and readily obtainable.

Clinical assessment of heart-type fatty acid binding protein in early diagnosis of acute coronary syndrome.

BACKGROUND: Early identification of acute coronary syndrome (ACS) in the emergency room is still a difficult task. The objective of this study is to estimate the reliability of heart-type fatty acid binding protein (H-FABP) in identifying ACS in the early stage of chest pain onset. METHODS: In a prospective multicentre study in emergency room patients with suspected ACS lasting less than 3 h, heart heart-type fatty acid binding protein (H-FABP) was compared with conventional biomarkers. Protein levels >7 ng/ml were considered positive results. RESULTS: A total of 419 patients were analyzed. Acute myocardial infarction was diagnosed in 148 patients (35%). H-FABP sensitivity was 60% (89 out of 148 patients), significantly higher than troponin T [19% (28 out of 148 patients); P<0,05]. Specificity of troponin T, however, [99% (270 out of 271 patients)] was better than H-FABP [88% (237 out of 271 patients)], though this was not statistically significant. CONCLUSION: H-FABP can be a useful early diagnostic biochemical marker, particularly within the first 6 h of symptoms, in patients attending the emergency department.