Redisplacement of reduced distal radius fractures in adults: does the type of casting play a role? The CAST study, a multicentre cluster randomized controlled trial.

Aims: It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer the redisplacement of fewer fractures and better one-year outcomes compared with plaster splinting. Methods: In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure. Results: The study included 420 patients. There was no significant difference between the rate of redisplacement of the fracture between the groups: 47% (n = 88) for those treated with a plaster splint and 49% (n = 90) for those treated with a circumferential cast (odds ratio 1.05 (95% confidence interval (CI) 0.65 to 1.70); p = 0.854). Patients treated in a plaster splint reported significantly more pain than those treated with a circumferential cast, during the first week of treatment (estimated mean NRS 4.7 (95% CI 4.3 to 5.1) vs 4.1 (95% CI 3.7 to 4.4); p = 0.014). The rate of complaints relating to the cast, clinical outcomes and PROMs did not differ significantly between the groups (p > 0.05). Compartment syndrome did not occur. Conclusion: Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups.

Routine alcohol screening in the ED: unscreened patients have an increased risk for hazardous alcohol use.

BACKGROUND: Routine screening programmes for hazardous alcohol use in the ED miss large numbers of patients. We investigated whether patient-related or staff-related factors cause screening failures and whether unscreened patients are at increased risk of hazardous alcohol use. METHODS: This is a secondary analysis of a prospective study. From November 2012 to November 2013, all adult patients visiting a Dutch inner city ED were screened for hazardous alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption. Reasons for failure of screening were categorised as: (A) patient is unable to cooperate (due to illness or pain, decreased consciousness or incomprehension due to intoxication, psychiatric, cognitive or neurological disorder or language barrier), (B) healthcare professional forgot to ask, (C) patient refuses cooperation and (D) screening was recently performed (<6 months ago). Presence of risk factors for hazardous alcohol use was compared between screened and unscreened patients. RESULTS: Of the 28 019 ED patients, 18 310 (65%) were screened and 9709 (35%) were not. In 7150 patients staff forgot to screen, whereas 2559 patients were not screened due to patient factors (2340 being unable and 219 unwilling). Patients with any of these risk factors were less likely to be screened: male sex, alcohol-related visit, any intoxication, head injury, any kind of wound and major trauma. In multivariate analysis, all these risk factors were independently associated with not being screened. Patients with at least one risk factor for hazardous alcohol use were less likely to be screened. Highest prevalence of risk factors was found in patients unable or unwilling to cooperate. CONCLUSION: Patients who do not undergo routine screening for alcohol use at triage in the ED have an increased risk for hazardous alcohol use. These data highlight the importance of screening patients, especially those initially unwilling or unable to cooperate, at a later stage.

Emergency department care for patients with mental health problems, a longitudinal registry study and a before and after intervention study.

OBJECTIVE: To describe the numbers and length of stay (LOS) of patients with mental health (MH) problems at a Dutch emergency department (ED) and the effect of a psychiatric intervention team (PIT) on patient flow. METHODS: A longitudinal design was used to assess number of MH presentations and LOS during a 3-year period (2014-2016). In 2017, we introduced a PIT during ED peak hours, to reduce LOS for patients with MH problems. We evaluate the effects of the PIT on patients' LOS with an 18-month before and after intervention study (2017-2018). RESULTS: Total number of ED presentations increased with 4%. Total number of MH presentations increased with 23% from 2014 to 2016. LOS increased by 28 min (95 min vs. 123 min) for all presentations, while not changing for MH presentations (2014: 195 min, interquartile range (IQR) 120-293 and 2016: 190 min, IQR 116-296). In the before and after intervention study, number of MH presentations increased with 36% while LOS decreased with 46 min (p < 0.001). CONCLUSIONS: The number of MH presentations increased over the three years while LOS remained similar. In the before and after intervention study, number of presentations increased even more while LOS decreased significantly. Specialist psychiatric input reduces ED LOS.

A different crowd, a different crowding level? The predefined thresholds of crowding scales may not be optimal for all emergency departments.

INTRODUCTION: Previous studies indicate that crowding scales may not perform well in low-volume emergency departments (EDs). In this study, face-validity of the Modified National ED OverCrowding Score (mNEDOCS) was assessed in a high-volume ED as well as in a low-volume ED. METHODS: A prospective observational cohort study was performed in the Netherlands. The correlation of the mNEDOCS with ED staff perceptions of crowding were assessed, using weighted Kappa (κ) and Pearson correlation. Subsequently, ED process measures (elapsed target times to triage, elapsed target times to treatment and patients' LOS) were described under different levels of ED crowding. RESULTS: Correlation between the categorized crowding scores was low (weighted κ 0.34 resp. 0.26). However, good correlations of 0.73 and 0.82 were found between the uncategorized mNEDOCS and ED staff's perception of crowding. Percentages of patients with elapsed target times to treatment increased simultaneously with increasingly busy periods when measured with mNEDOCS. CONCLUSIONS: The uncategorized mNEDOCS correlates well with perceived crowding, even at a low-volume ED. Determining a cut-off level at which a specific ED can be identified as crowded is important, because the predefined mNEDOCS categories may not be optimal for all EDs.

Assessing bottlenecks in Emergency Department flow of patients with abdominal pain.

INTRODUCTION: Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified. METHODS: Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study. RESULTS: In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure. CONCLUSIONS: Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.

Evaluation of screening and brief intervention for hazardous alcohol use integrated into clinical practice in an inner-city Emergency Department.

INTRODUCTION: In small studies, Screening, Brief Intervention and Referral to Treatment (SBIRT) in Emergency Departments (EDs) is effective in reducing hazardous alcohol use. OBJECTIVE: To examine the effectiveness of SBIRT at an inner-city ED in routine clinical practice. METHODS: Of the 41 900 consecutive ED patients aged 18 years and older, 22 537 (53.8%) were screened using the Alcohol Use Disorders Identification Test (AUDIT-C). Patients with positive AUDIT-C scores (men≥5 and women≥4) received educational leaflets. Brief interventions were performed by ED personnel trained in motivational interviewing. At 3 months, patients were contacted by telephone and recent drinking pattern was assessed. RESULTS: Out of 22 537 patients, 2209 (9.8%) had an elevated AUDIT-C score. Male sex, alcohol-related reason for ED visit, alcohol or other intoxication at ED visit, head injury, stomach or intestinal bleeding and wounds were significant predictors of hazardous alcohol use in both univariate and multivariate analysis (all P<0.001). Out of 2209 patients, 894 (40.5%) AUDIT-C-positive patients received an intervention: of these 894 patients, 70% received educational material and 30% received motivational intervention and educational material. In the subset of patients available for follow-up, 34.9% either reduced or stopped alcohol use. CONCLUSION: Our study shows that in a large inner-city ED, SBIRT can be implemented in daily care. Screening uncovered large numbers of patients with hazardous alcohol use and identified several risk factors. Moreover, screening and intervention appeared to be effective in reducing alcohol intake.