Triage-clinical reasoning on emergency nursing competency: a multiple linear mediation effect

BACKGROUND

Triage is the first step in providing prompt and appropriate emergency nursing and addressing diagnostic issues. Rapid clinical reasoning skills of emergency nurses are essential for prompt decision-making and emergency care. Nurses experience limitations in emergency nursing that begin with triage. This cross-sectional study explored the mediating effect of perceived triage competency and clinical reasoning skills on the association between Korean Triage and Acuity Scale (KTAS) proficiency and emergency nursing competency.

METHODS

A web-based survey was conducted with 157 emergency nurses working in 20 hospitals in South Korea between mid-May and mid-July 2022. Data were collected utilizing self-administered questionnaires to measure KTAS proficiency (48 tasks), perceived triage competency (30 items), clinical reasoning skills (26 items), and emergency nursing competency (78 items). Data were analyzed using the PROCESS macro (Model 6).

RESULTS

Perceived triage competency indirectly mediate the relationship between KTAS proficiency and emergency nursing competency. Perceived triage competency and clinical reasoning skills were significant predictors of emergency nursing competency with a multiple linear mediating effect. The model was found have a good fit (F = 8.990, P <.001) with, a statistical power of 15.0% (R² = 0.150).

CONCLUSIONS

This study indicates that improving emergency nursing competency requires enhancing triage proficiency as well as perceived triage competency, which should be followed by developing clinical reasoning skills, starting with triage of emergency nurses.

Hyperkalemia Detection in Emergency Departments Using Initial ECGs: A Smartphone AI ECG Analyzer vs. Board-Certified Physicians

BACKGROUND

Hyperkalemia is a potentially fatal condition that mandates rapid identification in emergency departments (EDs). Although a 12-lead electrocardiogram (ECG) can indicate hyperkalemia, subtle changes in the ECG often pose detection challenges. An artificial intelligence application that accurately assesses hyperkalemia risk from ECGs could revolutionize patient screening and treatment. We aimed to evaluate the efficacy and reliability of a smartphone application, which utilizes camera-captured ECG images, in quantifying hyperkalemia risk compared to human experts.

METHODS

We performed a retrospective analysis of ED hyperkalemic patients (serum potassium ≥ 6 mmol/L) and their age- and sex-matched non-hyperkalemic controls. The application was tested by five users and its performance was compared to five board-certified emergency physicians (EPs).

RESULTS

Our study included 125 patients. The area under the curve (AUC)-receiver operating characteristic of the application's output was nearly identical among the users, ranging from 0.898 to 0.904 (median: 0.902), indicating almost perfect interrater agreement (Fleiss' kappa 0.948). The application demonstrated high sensitivity (0.797), specificity (0.934), negative predictive value (NPV) (0.815), and positive predictive value (PPV) (0.927). In contrast, the EPs showed moderate interrater agreement (Fleiss' kappa 0.551), and their consensus score had a significantly lower AUC of 0.662. The physicians' consensus demonstrated a sensitivity of 0.203, specificity of 0.934, NPV of 0.527, and PPV of 0.765. Notably, this performance difference remained significant regardless of patients' sex and age (P < 0.001 for both).

CONCLUSION

Our findings suggest that a smartphone application can accurately and reliably quantify hyperkalemia risk using initial ECGs in the ED.

The burden and management strategies of hypertensive crisis in adult patients presenting to emergency departments of district and regional hospitals in Sub-Saharan Africa

BACKGROUND

Hypertensive crisis is among the causes of morbidity and mortality in adult patients with hypertension in Sub-Saharan Africa. We aimed to determine the burden, risk factors and describe the management strategies of hypertensive crisis among adult patients seen at emergency departments of district and regional hospitals in Tanzania.

METHODS

This was a prospective multicenter longitudinal study which included all 162 district and regional hospitals in Tanzania. It was part of the Tanzania Emergency Care Capacity Survey (TECCS), a large assessment of burden of acute illness and emergency care capacity in Tanzania. Adult patients who presented to emergency departments with blood pressure ≥ 180/110mmHg were enrolled. Demographics, clinical presentation, management, and 24-hours outcomes were recorded using a structured case report form. Descriptive statistics were summarized in frequency and median, while logistic regression was used to evaluate the association between risk factors and presence of hypertensive crisis.

RESULTS

We screened 2700 patients and enrolled 169 adults, henceforth proportion of adult patients with hypertensive crisis was 63 per 1000. Median age was 62 years (IQR 50-70 years) and predominantly females, 112 (66.3%). Majority 151(89.3%) were self-referred with two-wheel motorcycle being the commonest 46 (27.2%) mode of arrival to the hospital. Hypertensive emergency was found in over half 96 (56.8%) of the patients with hypertensive crisis, with oral medications administered in more than half of them, 71 (74%) as means to control the high blood pressure, and one-third 33 (34.4%) were discharged home. On multivariate analysis increasing age (AOR 4.53, p < 0.001), use of illicit drug (AOR 4.14, p-0.04) and pre-existing hypertension (AOR 8.1, p < 0.001) were independent risk factors for hypertensive crisis occurrence.

CONCLUSION

Hypertensive crisis among adult patients attending district and regional hospitals is common (63 patients per every 1000 patients). Increasing age, use of illicit drug and pre-existing hypertension are independent associated factors for developing hypertensive crisis.

New Zealand emergency nurses' perspectives and experiences of professional joy in clinical practice: An exploratory qualitative study

BACKGROUND

Nursing is becoming an increasingly stressful occupation, identified by high rates of burnout, compounded by a worldwide nursing shortage. Differing solutions to combat burnout have not provided long-term positive outcomes. This research explored emergency nurses' perspectives and experiences of one potential solution, known as joy in work, or professional joy.

METHODS

A qualitative, descriptive design was used to conduct semi-structured interviews with six registered nurses from two New Zealand emergency departments. Thematic analysis techniques were used.

FINDINGS

Professional joy was frequently experienced, despite the difficulties faced in the emergency environment. Joy was identified as being like a spark which provided an uplift. The experience of joy positively impacted the nurse, and beyond, and potentially provided a buffer that assisted with mitigating the daily challenges. Recalling or sharing experiences of joy evoked a sense of wellbeing in the nurse, which in turn provided motivation to keep on nursing. This research identified a link between nurse wellbeing, joy and the importance of a healthy work environment.

CONCLUSION

While this study was relatively small, the findings highlight the significant positive impact the experience of joy had on these nurses. Further research is recommended to gain greater understanding of this important topic.

Incidence of idiopathic benign paroxysmal positional vertigo subtype by hospital visit type: experience of a single tertiary referral centre

OBJECTIVE

To investigate the incidence of benign paroxysmal positional vertigo subtype by hospital visit type (i.e. out-patient department vs emergency room), in a single tertiary referral centre.

METHODS

A total of 772 consecutive patients with benign paroxysmal positional vertigo were included. Using head-roll and Dix-Hallpike tests, benign paroxysmal positional vertigo subtype was determined as canalolithiasis posterior semicircular canal benign paroxysmal positional vertigo, geotropic horizontal semicircular canal benign paroxysmal positional vertigo or apogeotropic benign paroxysmal positional vertigo.

RESULTS

The posterior semicircular canal benign paroxysmal positional vertigo patients who were evaluated via the out-patient department outnumbered those evaluated via the emergency room, while those with horizontal semicircular canal benign paroxysmal positional vertigo who were evaluated via the emergency room outnumbered those evaluated via the out-patient department.

CONCLUSION

A significantly higher proportion of patients who visited the emergency room had horizontal semicircular canal benign paroxysmal positional vertigo than posterior semicircular canal benign paroxysmal positional vertigo. These results suggest that the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo might be higher than previously reported.

Ambient temperature and atmospheric pressure at discharge as precipitating factors in immediate adverse events in patients treated for decompensated heart failure

To investigate the relationship of ambient temperature and atmospheric pressure (AP) at patient discharge after an episode of acute heart failure (AHF) with very early post-discharge adverse outcomes. We analyzed 14,656 patients discharged after an AHF episode from 26 hospitals in 16 Spanish cities. The primary outcome was the 7-day post-discharge combined adverse event (emergency department -ED- revisit or hospitalization due to AHF, or all-cause death), and secondary outcomes were these three adverse events considered individually. Associations (adjusted for patient and demographic conditions, and length of stay -LOS- during the AHF index episode) of temperature and AP with the primary and secondary outcomes were investigated. We used restricted cubic splines to model the continuous non-linear association of temperature and AP with each endpoint. Some sensitivity analyses were performed. Patients were discharged after a median LOS of 5 days (IQR = 1-10). The highest temperature at discharge ranged from - 2 to 41.6 °C, and AP was from 892 to 1037 hPa. The 7-day post-discharge combined event occurred in 1242 patients (8.4%), with percentages of 7-day ED-revisit, hospitalization and death of 7.8%, 5.1% and 0.9%, respectively. We found no association between the maximal temperature and AP on the day of discharge and the primary or secondary outcomes. Similarly, there were no significant associations when the analyses were restricted to hospitalized patients (median LOS = 7 days, IQR = 4-11) during the index event, or when lag-1, lag-2 or the mean of the 3 post-discharge days (instead of point estimation) of ambient temperature and AP were considered. Temperature and AP on the day of patient discharge are not independently associated with the risk of very early adverse events during the vulnerable post-discharge period in patients discharged after an AHF episode.

A profile of traumatic brain injury within hospital emergency departments - a retrospective study in the Republic of Moldova

Background

Traumatic brain injury (TBI) is a critical public health and socio-economic problem throughout the world, making epidemiological monitoring of incidence, prevalence, and outcome of TBI necessary. TBI is a major cause of mortality and morbidity in adolescents, young adults, and the elderly, one of the leading causes being road traffic accidents.

Methods

A retrospective study was conducted among patients with TBI within 2 medical institutions from Chisinau municipality: Emergency Medicine Institute (EMI) and Valentin Ignatenco Municipal Children's Hospital (MCH). A questionnaire was applied, completed on the basis of medical records according to the International Classification of Diseases (ICD) 10 codes. The collection period was August, 1 - October 31, 2018. Data were uploaded using the existing electronic data collection tool - Red Cap and analyzed through Microsoft Excel. Data collection was performed by a resident neurosurgery and a scientific researcher. The ethics committee's approval has been obtained.

Results

There have been identified 150 patients: 57 cases (38.5%) of TBI among children and 93 cases (61.5%) among adults aged between 18-73 years old. A large majority (62%) of head injuries were among patients from the urban area (most in adults - 60% and males - 74%). The most common mechanisms of head injury were falls (53.3%) and road traffic injuries (24%), followed by assault (14.7%) and struck by/or against (8%). The distributions by place of occurrence highlighted that most injuries occurred at home (33.4%) and transport area (25.3%). Most head injuries were registered among men 121(81.2%) with a predominance of minor Glasgow Coma Scale (GCS) (65.1%), followed by moderate GCS (9.4%), while in women all cases with GCS minor (18.8%).

Conclusion

The data obtained could be useful for the hospital administration in managing the necessary resources and for conducting information campaigns among the high-risk groups.

A Systematic Literature Review Identifying the Dimensions and Components of Simulation of the Hospital Emergency Department During Emergencies and Disasters

Background: The use of simulation in medical education is evolving widely around the world. Hospital emergency services in the event of accidents and disasters affect the quality of health care. It is critical to determine the fundamental features for developing a hospital emergency department simulation to improve emergency services. In this regard, the current study conducted a comprehensive assessment of studies with the determinations and components of hospital emergency department simulation during accidents and disasters. Methods: In this systematic literature review, all studies between January 2010 and July 2021 were searched in MEDLINE/PubMed, EMBASE, ProQuest, Scopus, Web of Science, Iran medex Google Scholar, and Scientific Information Database (SID), MagIran databases and were analyzed with the thematic analysis approach and results were expressed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The quality of the included studies was assessed using related checklists. Results: The findings of this study were divided into 3 main categories and 10 subcategories, including factors related to manpower (manpower arrangement, performance-awareness-skills, safety, and communication), factors related to medical services (triage, time, and transfer of the injured), and factors related to resource management and support (physical environment, equipment, and the information system). Conclusion: Through systematic planning, simulation allows for the identification of emergency department difficulties during accidents and disasters. Identifying dimensions and components, such as resource management and support, manpower, and medical services, is effective in designing the simulation of the hospital emergency department during accidents and disasters. Therefore, it is recommended to conduct future studies with a qualitative approach and focus on the factors affecting the simulation of the hospital emergency department during disasters, which has been done by the same researchers.

Ontology for Overcrowding Management in Emergency Department

Emergency department (ED) overcrowding is an ongoing problem worldwide. Scoring systems are available for the detection of this problem. This study aims to combine a model that allows the detection and management of overcrowding. Therefore, it is crucial to implement a system that can reason model, rank ED resources and ED performance indicators based on environmental factors. Thus, we propose in this paper a new domain ontology (EDOMO) based on a new overcrowding estimation score (OES) to detect critical situations, specify the level of overcrowding and propose solutions to deal with these situations. Our approach is based on a real database created during more than four years from the Lille University Hospital Center (LUHC) in France. The resulting ontology is capable of modeling complete domain knowledge to enable semantic reasoning based on SWRL rules. The evaluation results show that the EDOMO is complete that can enhance the functioning of the ED.

The interplay between acute post-traumatic stress, depressive and anxiety symptoms on healthcare workers functioning during the COVID-19 emergency: A multicenter study comparing regions with increasing pandemic incidence

BACKGROUND

Healthcare workers (HCWs) deployed to the frontline during the COVID-19 pandemic are at risk for developing mental disorders, with a possible impact on their wellbeing and functioning. The present study aimed at investigating post-traumatic stress symptoms (PTSS), anxiety and depressive symptoms and their relationships with impairment in the functioning impairment among frontline HCWs from three Italian regions differently exposed to the first wave of the COVID-19 emergency: Tuscany (low), Emilia-Romagna (medium) and Lombardy (high).

METHODS

514 frontline HCWs were consecutively enrolled in hospital units devoted to the treatment of COVID-19 patients. They completed the IES-R, PHQ-9 and GAD-7 to assess PTSS, depressive and anxiety symptoms respectively, and the WSAS to investigate functioning impairment.

RESULTS

A total of 23.5% of HCWs reported severe PTSS, 22.4% moderate-severe anxiety symptoms, 19.3% moderate-severe depressive symptoms and 22.8% impairment in global functioning. HCWs from the higher-exposure regions reported significantly higher scores in all instruments than those from lower-exposure regions. In a multiple linear regression model, PTSS, depressive and anxiety symptoms presented a significant positive association with the functioning impairment. Both PTSS and depression resulted to be independently related to functioning impairment.

LIMITATIONS

The cross-sectional design and the use of self-report instruments.

CONCLUSIONS

Depressive and PTSS appear to be the greatest contributors to functioning impairment in HCWs exposed to a massive stressful sanitary event as the COVID-19 pandemic. A more accurate assessment of work-related mental health outcomes in such population could help planning effective prevention strategies and therapeutic interventions.

Crowd-Out and Emergency Department Utilization

When consumers gain Medicaid, their cost of healthcare changes. The direction of this change determines how utilization changes. The previously uninsured see a stark decrease in the price of primary care after gaining public insurance. Due to charity care, they may face an increase in the price of emergency department care. The previously insured see a reduction in emergency department prices and decreased access to primary care. We examine the impact of the prior insurance status of the newly publicly insured on substitution between healthcare. We base our identification on California's LIHP and ACA Medicaid expansions. One challenge we face is estimating crowd-out. We use machine learning techniques to predict prior insurance status based on observable covariates in cross-sectional data. We find an increase in emergency department utilization caused entirely by those crowded-out whose access to primary care has decreased. We find the opposite utilization patterns for the previously uninsured.

Facilitators, barriers and opportunities in workplace wellbeing: A national survey of emergency department staff

INTRODUCTION

Emergency department (ED) staff face daily exposure to the illness, injury, intoxication, violence and distress of others. Rates of clinician burnout are high and associated with poor patient outcomes. This study sought to measure the prevalence of burnout in ED personnel as well as determine the important facilitators of and barriers to workplace wellbeing.

METHOD

An anonymous online survey including six open-ended questions on workplace wellbeing was completed by 1372 volunteer participants employed as nurses, doctors, allied health or nonclinical roles at 22 EDs in Aotearoa, New Zealand in 2020. Responses to the questions were analysed using a general inductive approach.

RESULTS

The three key themes that characterise what matters most to participants' workplace wellbeing are: (1) Supportive team culture (2) Delivering excellent patient-centred care and (3) Professional development opportunities. Opportunities to improve wellbeing also focused on enhancements in these three areas.

CONCLUSION

In order to optimise workplace wellbeing, emergency departments staff value adequate resourcing for high-quality patient care, supportive and cohesive teams and professional development opportunities. Initiatives in these areas may facilitate staff wellbeing as well as improving safety and quality of patient care.

Media framing of emergency departments: a call to action for nurses and other health care providers

BACKGROUND

As part of a larger study focused on interventions to enhance the capacity of nurses and other health care workers to provide equity-oriented care in emergency departments (EDs), we conducted an analysis of news media related to three EDs. The purpose of the analysis was to examine how media writers frame issues pertaining to nursing, as well as the health and social inequities that drive emergency department contexts, while considering what implications these portrayals hold for nursing practice.

METHODS

We conducted a search of media articles specific to three EDs in Canada, published between January 1, 2018 and May 1, 2019. Media items (N = 368) were coded by story and theme attributes. A thematic analysis was completed to understand how writers in public media present issues pertaining to nursing practice within the ED context.

RESULTS

Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses. Second, media writers portray pressures experienced by nurses working in the ED in a way that evades structural determinants of quality of care. Underlying both themes is an absence of perspectives and authorship from practicing nurses themselves.

CONCLUSIONS

We recommend that frontline nurses be prioritized as experts in public media communications. Nurses must be supported to gain critical media skills to contribute to media, to destigmatize the health care needs of people experiencing inequity who attend their practice, and to shed light on the structural causes of pressures experienced by nurses working within emergency department settings.

Games People Play: Lessons on Performance Measure Gaming from New Zealand Comment on "Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?"

For decades, observers have noted that gaming of performance measurement appears to be both endemic and endlessly creative. A recent study by Tenbensel and colleagues provides a detailed look at gaming of a health system performance measure—emergency department (ED) wait times—within four hospitals in New Zealand. Combined, these four hospitals handled more than 25% of the ED visits in the country each year. Tenbensel and colleagues examine whether the New Zealand ED wait time target was set appropriately and whether we can trust any performance measure statistics that are not independently verified or audited. Their thoughtprovoking examination is relevant to anyone working in quality improvement and provides a valuable set of tools for detecting gaming in performance measurement.

Home accidents in the province of Trento. Ten years of observations regarding admissions to the emergency and first aid department

BACKGROUND

Home accidents, or domestic accidents, are accidents that occur inside a home or the adjacent areas (stairways, courtyards, gardens, attics, cellars, garages, etc.). In Italy, they are monitored through a number of surveillance systems including the PASSI system and the ISTAT (Italian Institute of Statistics) Multipurpose Survey on Households. Only the SINIACA system (Italian National Information Service on Domestic Accidents), managed by the Istituto Superiore di Sanità (National Institute for Health), provides health-related information regarding such events and their circumstances and consequences, based primarily on Accident & Emergency Departments' data.

STUDY DESIGN

This is an observational study on the domestic accidents trends in the province of Trento, using data on Accident & Emergency Departments admissions, between 2009 and 2018, combined with mortality and hospital discharge data.

METHODS

The authors extrapolated records regarding admissions for domestic accidents from the digital annual Accident & Emergency admissions archive. For the 2009-2018 period, they analysed: the trend over time, both overall and classified according to gender and age group; and the inflow rate/10,000 inhabitants, broken down according to gender, nationality (Italians and foreign nationals) and age group. The coverage of the additional SINIACA variables regarding the accident dynamic, contingent activity and place of the accident were also analysed. With regard to the case load for 2018, the authors analysed the site and type of the injuries, the level of severity, outcome and the services provided, comparing the 0-14 years and >65 years age groups. Trend significance was analysed using the Cochran-Armitage test for trend and the significance of the differences between the proportions was analysed using the Chi-squared test. We have also calculated the costs of the services provided, overall and by age group.

RESULTS

During the study period, a total of 99,386 A&E admissions for domestic accidents were recorded, with an annual average of 9,938 admissions. Between 2009 and 2018, there was a statistically significant increase of 41%, which was due in part to better event recognition and recording. Females prevail over males, especially over the age of 75 years. Over time there is an increase in cases over the age of 65, due to the progressive ageing of the population. Considering the resident population alone, the A&E inflow rate rises from 147 admissions/10,000 inhabitants in 2009 to 197 admissions/10,000 inhabitants in 2018, with a 39.0% increase. Inflow is greater in the two extreme age groups: in 2018, in the 0-4 years age group, the inflow rate is 319 admissions/10,000 inhabitants and in the over 75 years class it rises to 481 admission/10,000 inhabitants, 1.6 and 2.4 times the mean inflow for home accidents in the province of Trento, respectively. Admissions are less amongst foreign nationals than amongst Italians. Generally speaking, the events were of a mild severity, with white triage codes accounting for 16% of cases and green triage codes for 73%. The degree of severity is higher amongst subjects aged over 65, as well as in women and Italian citizens.The level of recording of SINIACA variables increases over time, to reach 100% coverage in 2018. Falls are the most common dynamic in all age ranges; household chores, activities of daily living and DIY are the three most commonly observed activities. Home accidents most commonly occur in the areas adjacent to the home and the kitchen. In over 2/3 of cases, the injuries sustained were to the limbs and the head/face. Head/face injuries prevail in the youngest age group. Wounds, burns and head injuries are the most common types of injury sustained by children in the 0-14 years age group, whereas fractures and dislocations are typical of the older age groups. Diagnostic and care resource consumption is far higher amongst the elderly, which absorb 61% of the total costs of the cases treated in the year 2018.

CONCLUSION

Accident & Emergency facilities provide a privileged observatory for the monitoring of domestic accidents in the population. By comparing our data with the ISTAT data, it can be estimated that 1 in 2 home accidents in the population resulted in an A&E admission. Admissions increase over time, particularly amongst the elderly and they are not higher amongst foreign nationals than amongst Italians. The inflow rate is higher in the extreme age ranges: 0-4 and >75 years; however, there are differences between the two in terms of type of injury, level of severity and outcome. It is essential for A&E admission data to be fully digitalised, and facility and staff sensitisation is also important in order to guarantee the availability of good-quality data. The completeness of A&E data and the possibility of obtaining case stratification based on social and demographic characteristics could make it possible, through a virtuous integration of services, to use these data for the implementation of prevention initiatives. These, if carried out effectively, could also contribute to contain healthcare costs.

[Ocular trauma in the Pediatric Emergency Departments, characteristics and risk factors of immediate sequelae]

OBJECTIVE

This study assesses the clinical characteristics and epidemiology of children with eye trauma presenting to the Emergency Department in Spain and analyze the risk factors associated with immediate sequelae.

METHODS

A multicentric prospective case series study conducted during 24 months of patients presenting to the Pediatric Emergency Departments in five hospitals collaborating with the Spanish Pediatric Emergency Research Group. Data were collected from October 2016 through September 2018, including all patients up to the age of 16 years old presenting to the Emergency Department with an ocular trauma. All injuries were classified by Birmingham Eye Trauma Terminology.

RESULTS

A total of 242,134 visits to the Emergency Departments took place during the study period, being 1,007 ocular traumas (0.42%; IC 95% 0.40-0.45) and 858 were included in the study. Most commonly, injuries occurred while playing (54.7%), except in the 15 or more-age group, in which sports activities were more common (23.1%). The place of the trauma varied depending on the age group, being home (34.7%) and schools or sports areas (34.3%) the most recurrent. Blunt objects were the most frequent mechanism of trauma (48.6%). Most of the injuries were classified as closed globe (85.5%), mainly contusions (52.7%). Fifty-eight patients (6.8%) presented with immediate sequelae, being the impairment of visual acuity the most common (70.7%). The risk factors associated with immediate sequelae were the 10 or more-age group, the preexisting refractive errors, the open globe injuries and the injuries with blunt objects.

CONCLUSIONS

Ocular trauma is a frequent chief complaint in the Pediatric Emergency Departments in Spain. Increasing awareness of the serious nature of ocular injuries and the study of the risk factors will help to develop a comprehensive plan for educating both parents and children to minimize preventable eye injuries sequelae.

Coping With Trauma, Celebrating Life: Reinventing Patient And Staff Support During The COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic presented unprecedented challenges to the New York City Health + Hospitals system. In addition to ramping up capacity and adapting operations quickly to handle the patient surge, NYC Health + Hospitals had to find new ways to provide emotional and psychological support for patients, families, and staff. To help families keep in touch, dedicated staff members provided daily updates by telephone and used tablets for virtual visits. An expanded palliative care team held virtual consultations with families to discuss advance care planning and end-of-life decisions. Bereavement hotlines were set up for families who lost loved ones. Enhanced staff support included one-on-one and group sessions with behavioral health specialists, a behavioral health hotline, a webinar series, and respite rooms, as well as complimentary lodging and child care. NYC Health + Hospitals created new rituals to celebrate recoveries and mourn losses. As regular operations resume, NYC Health + Hospitals plans to sustain and build on emotional and psychological support initiatives developed during the surge.

Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?

BACKGROUND

Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations.

METHODS

We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n=68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data.

RESULTS

Our research established that gaming behaviour - in the form of 'clock-stopping' and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches - was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff.

CONCLUSION

Gaming of New Zealand's ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game.

Sickle-Cell Disease Co-Management, Health Care Utilization, and Hydroxyurea Use

BACKGROUND

Sickle-cell disease (SCD) causes significant morbidity, premature mortality, and high disease burden, resulting in frequent health care use. Comanagement may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute-care utilization in Medicaid-enrolled patients with SCD, patient factors associated with comanagement, and adherence to Hydroxyurea.

METHODS

Data from 2790 patients diagnosed with SCD, age 1 to 65+ years, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017, were analyzed. Outpatient visits were categorized as primary care, hematologist, and nonhematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Comanagement was defined as a minimum of 1 primary care and 1 hematologist visit/patient during the study period.

RESULTS

There were notable age-related differences in utilization of health care services. Only 34.82% of the sample was comanaged. Comanagement was higher in the 1-to-9-year-old (44.88%) and 10-to-17-year-old groups (39.22%) versus the 31-to-45-year-old (30.26%) and 65+-year-old (18.75%) age groups. Age had the greatest influence (AUC = 0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least 1 Hydroxyurea (HU) prescription. Age was the most predictive factor of good HUadherence (AUC = 0.6503). Prediction by comanagement was minimal with an AUC = 0.5615.

CONCLUSION

Comanagement was a factor in predicting HUadherence, but further studies are needed to identify the frequency and components of comanagement needed to increase adherence and reduce acute care utilization.

Bed Tracking Systems: Do They Help Address Challenges in Finding Available Inpatient Beds?

OBJECTIVE

Locating open beds in hospital and residential mental health and substance use disorder treatment settings has been an ongoing challenge in the United States. The inability to find open beds has contributed to long emergency department wait times and missed opportunities to engage patients in treatment. Increasingly, states are creating online bed tracking systems to improve access to timely information about bed availability. This study aimed to document how states are implementing bed tracking systems, their successes and challenges, and lessons learned.

METHODS

A review was conducted of the published and gray literature available between 2008 and 2018, and 13 interviews were conducted with 18 stakeholders in five states (Connecticut, Iowa, Kansas, Massachusetts, and Virginia).

RESULTS

The authors identified 17 states with bed tracking systems, of which five make information available to consumers. Most interviewees reported that the bed tracking systems were improving the ability of providers and consumers to more readily locate openings. Challenges identified included that some hospitals will not participate in bed registries, data on bed availability is sometimes not timely enough, bed registries do not provide enough detail on whether the facility is capable of meeting a particular patient's needs, providers have not been coached to use the bed registry system and continue existing practices, and states that provide information to the public have not publicized the registry's existence.

CONCLUSIONS

Bed tracking systems offer promise, but more needs to be done to understand how to realize their potential and to more widely implement lessons learned.

Assessing and responding to anxiety and panic in the Emergency Department

Anxiety and panic symptoms are widespread in the general population. The physical manifestations of anxiety and panic commonly account for people presenting to Emergency Departments (EDs). It is therefore important for ED clinicians to be informed of the numerous causes of anxiety and panic and equipped to respond effectively. This paper describes the underlying pathophysiology of the physical symptoms of anxiety and panic and differential diagnoses to consider. Organic conditions that are associated with symptoms of anxiety and panic are highlighted. Brief interventions are tabled for ED clinicians to use when explaining symptoms, and to promote individual self-management.

Emergency Department High Utilizers among Family Medicine Patients

BACKGROUND

Increases in emergency department (ED) use are contributing to inefficient health care spending and becoming a public health concern. Previous studies have identified characteristics of ED high utilizers aimed at designing interventions to improve efficiency. We aim to expand on these findings in a family medicine outpatient population.

METHODS

We conducted a retrospective analysis on a population of ED high utilizers, defined as those who had been to the ED 6 or more times in 1 year, including medical and demographic characteristics from 2015 to 2017.

RESULTS

Compared with our source population, ED high utilizers were most commonly female, African American, or single and insured by Medicare or Medicaid. They did not have a chronic pain or substance use diagnosis, but more than half had a psychiatric condition. The only demographic characteristic that changed over time was home location from 2015 to 2017 (P < .05). Less than 10% of ED high utilizers were the same over 3 years.

CONCLUSIONS

Most demographic characteristics did not change over time, whereas individuals did change. Interventions aimed at improving efficiency of ED use should be geared toward unchanging characteristics rather than individuals. The only demographic characteristic that did change significantly was home location that correlated in time with the availability of new EDs providing support for a theory of supply-sensitive ED use.

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011-2013

BACKGROUND

Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment.

OBJECTIVES

This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care.

METHODS

The 2011-2013 Healthcare Cost and Utilization Project's NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively.

RESULTS

A total of 492,419 ED visits for SUDs were reported through 2011-2013. Despite NY's Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York's EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.

"It's Really Overwhelming": Patient Perspectives on Care Coordination

PURPOSE

Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department (ED) patient satisfaction and dissatisfaction with their care coordination.

METHODS

Semistructured telephone interviews were conducted with 25 adult patients following ED visits about their experiences with their care coordination. All patients interviewed had 2 or more ED visits and hospitalizations in the past year and/or health providers in more than one health system. Interview transcripts were coded and analyzed following a modified grounded theory approach.

RESULTS

Four broad categories of themes emerged from the patient interviews covering the following: (1) perceptions of care coordination between their providers, (2) the role of electronic health records, (3) challenges with information exchange between health systems, and (4) sources of support for care coordination activities, emphasizing the important role of the primary care provider.

CONCLUSIONS

Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.

Strategies for Addressing the Challenges of Patient-Centered Medical Home Implementation: Lessons from Oregon

BACKGROUND

Patient-centered medical homes (PCMHs) are at the forefront of the transformation of primary care as part of health systems reform. Despite robust literature describing implementation challenges, few studies describe strategies being used to overcome these challenges. This article addresses this gap through observations of exemplary PCMHs in Oregon, where the Oregon Health Authority supports and recognizes Patient-Centered Primary Care Homes (PCPCH).

METHODS

Twenty exemplary PCPCHs were selected using program scores, with considerations for diversity in clinic characteristics. Between 2015 and 2016, semistructured interviews and focus groups were completed with 85 key informants.

RESULTS

Clinics reported similar challenges implementing the PCPCH model, including shifting patterns of care use, fidelity to the PCPCH model, and refining care processes. The following ten implementation strategies emerged: expanding access through care teams, preventing unnecessary emergency department visits through patient outreach, improved communication and referral tracking with outside providers, prioritization of selected program metrics, implementing patient-centered practices, developing continuous improvement capacity through committees and "champions," incorporating preventive services and chronic disease management, standardization of workflows, customizing electronic health records, and integration of mental health.

CONCLUSION

Clinic leaders benefited from understanding the local context in which they were operating. Despite differences in size, ownership, geography, and population, all clinic leaders were observed to be proponents of strategies commonly associated with a "learning organization": systems thinking, personal mastery, mental models, shared vision, and team. Clinics can draw on their own characteristics, use state resources, and look to established PCMHs to build the evidence base for implementation in primary care.

[Emergency department consultations associated with unintentional injuries: A cases series]

OBJECTIVE

To analyse the clinical and epidemiological characteristics of children who are attended in Emergency Departments (EDs) for an unintentional injury in Spain.

METHODS

Multicentre case series with prospective data collection conducted during 12 months in the ED of 11 hospitals belonging to the Spanish Paediatric Emergency Research Group. Data were collected between September 2014 and January 2015, continuing for one year in all paediatric EDs, and included children between 0 and 16 years old seen for an unintentional injury.

RESULTS

A total of 10,175 episodes were recorded during the study, of which 1,941 were due to unintentional injuries (19.1%, 95% CI: 18.3%-19.8%), and 1,673 of these were included in the study. Falling, direct injuries, and injuries due to sports activities represented more than 80%, with significant variations in the injuries mechanism observed in different age groups. More than occurred at home or school. About 40% of the unintentional injuries were not witnessed by an adult. The most frequent diagnosis was limb trauma (63.0%), with a fracture being observed in 242 (14.4% of unintentional injuries). As regards fractures, 34 (2.0%) were admitted to hospital, with 21 (61.8%) for surgical reduction of the fracture. No deaths were recorded in the first 24h.

CONCLUSIONS

Unintentional injuries constitute a very common reason for consultation in EDs in Spain. The circumstances surrounding the unintentional injuries should be considered, in order to develop preventive measures and to improve the training of people involved in the care of these children.

Predicting 30-day mortality in patients with primary intracerebral hemorrhage: Evaluation of the value of intracerebral hemorrhage and modified new intracerebral hemorrhage scores

Background: Different criteria have been proposed to determine the mortality rate of primary intracerebral hemorrhage (ICH). This study aimed to evaluate ICH and Modified New ICH scores in predicting 30-day mortality in patients with primary ICH. Methods: In this prospective cohort study, 107 patients diagnosed with primary ICH were enrolled at an interval of six months (October 2015-March 2016). They were evaluated using Modified New ICH and ICH scores. The Modified New ICH score was different from the New ICH score since the National Institute of Health Stroke Scale (NIHSS) variables were replaced by Modified Rankin Scale (MRS) in the modified score. Results: A total of 61 patients (57%) died, and 46 (43%) survived during the 30-day hospitalization. ICH ≥ 2 and Modified New ICH ≥ 3 scores predicted 30-day mortality rate in patients with the sensitivity and specificity rates of 87 and 63 percent, and 88 and 53 percent, respectively. Conclusion: The current study showed that both ICH and Modified New ICH scores were almost equally effective in determining the mortality rate in patients with primary ICH, and both criteria had acceptable value in determining the mortality rate of patients. Therefore, routine assessment of ICH and Modified New ICH scores in patients with ICH in emergency wards is recommended.

Don't neglect the clock drawing test

INTRODUCTION

A 63-year-old, right-handed woman with a history of hypertension presented to the ED with left arm paresis of 2 days duration. Three weeks before admission, she had flu-like symptoms with intermittent left arm weakness that had recovered briefly but recurred 2 days prior to her presentation. On neurological examination, GCS was 15 and cranial nerves' function was normal. Left upper limb strength was 4/5. There was left arm drift and pronation but the patient denied noticing any difference between the positions of her arms. Hyper-reflexion was presented in the left arm. The rest of her motor, cerebellar, sensation and gait functions were normal. She was asked to draw a clock and set it to 15:30 (figure 1).emermed;35/1/38/F1F1F1Figure 1Clock drawing test results.

QUESTION

What is the most probable aetiology?Right cerebral bleeding involving the occipital lobeRight middle cerebral artery occlusionRight parietal lesion, likely neoplasmLeft cortical stroke.

The Effect of Having a Regular Doctor as a Primary Care Provider on Emergency Room Utilization in South Korea

Background

Because primary care is the cornerstone of an effective health care system, many developed countries have striven to establish and strengthen their primary care systems. However, the primary care system in South Korea is not well established, and primary care research is still in its infancy. This study aimed to show the benefits of regular doctors as primary care providers in South Korea by analyzing the effect of regular doctor visits on emergency room (ER) visits.

Methods

We analyzed cross-sectional data on 11,293 adults aged 18 years and over collected from the 2013 Korea Health Panel Survey (beta version 1.0). We classified those participants with and without regular doctors into the treatment and control groups, respectively, and estimated the average treatment effect (ATE) of having a regular doctor on ER visits. We used counterfactual framework and propensity score analysis to adjust for unevenly distributed confounding covariates between treatments and control groups.

Results

The estimated conditional ATE of a regular doctor on ER visits was statistically insignificant in the general population (-0.4%; 95% confidence interval [CI], -2.0 to 1.2) and in the subgroup of patients with hypertension (-1.8%; 95% CI, -4.5 to 0.9). However, in patients with diabetes mellitus (DM), the estimated ATE was statistically significant (-5.0; 95% CI, -9.2 to -0.7).

Conclusion

In the total study population, having a regular doctor did not result in a significant difference in ER visits. However, there was a decrease in ER visits in patients with DM in South Korea.

Effect of Continuity of Care on Emergency Department Visits in Elderly Patients with Asthma in Taiwan

BACKGROUND

Continuity of care (COC) is positively associated with health care outcomes. However, the effect of COC on the reduction of asthma-related emergency department (ED) visits among older asthmatic patients is not clearly understood.

METHODS

We conducted a retrospective cohort study using the Taiwan nationwide health insurance claims database between 2004 and 2013. Patients aged 65 years with asthma during 2005 to 2011 were selected. The COC index (COCI) is used to measure the number of individual physicians a patient sees in the first year and we identified asthma-related ED visit in the subsequent year. Cox model was used to examine the hazard ratio (HR) between COC and an ED visit for asthma.

RESULTS

Among a total of 3395 subjects, the overall mean COC was 0.73, and 48.5% of subjects had perfect COC (COCI = 1). After controlling for covariables, in the group of patients with low COC, the risk of having an asthma-related ED visit was higher compared with those with perfect COC (Adjusted HR, 2.11; 95% CI, 1.37-3.25).

CONCLUSIONS

Elderly asthmatic patients with lower COC had a significantly higher likelihood of having asthma-related ED visits.

Emergency department syndromic surveillance to investigate the health impact and factors associated with alcohol intoxication in Reunion Island

In Reunion Island, alcohol is the most tried out psychoactive substance. To our knowledge, few indicators measuring the health burden of alcohol use exist on the island. In this context, an exploratory analysis based on syndromic surveillance data was implemented in order to describe the emergency department (ED) visits for alcohol intoxication (AI) and factors associated with their variations.An analysis of anonymized records routinely collected by the syndromic surveillance system was carried out. A daily indicator of ED visits for AI was built from a selection of ICD-10 codes between 2010 and 2012. Health impact of AI was first described comparing this indicator to all causes ED visits. Then, AI visits were analyzed with time-series methods using generalized additive Poisson regression models allowing for overdispersion. The following variables were included in the model: long-term trend, seasonality, day of the week, public and school holidays, days of festival and minimum social benefits payday.During the study period, 16 652 visits for AI were recorded in EDs of Reunion Island. AI visits were the second reason for ED visits (i.e. 4%) after traumatism. AI visits mainly concerned men (87%) and the age group of 25-54 years (69%). There was a significant increase in ED visits for AI during days of benefits payday, weekends and publics holidays.This study demonstrated the interest of syndromic surveillance to monitor non-infectious diseases. Time-series models showed a robust association between ED visits for AI and several factors.

System Transformation in Patient-Centered Medical Home (PCMH): Variable Impact on Chronically Ill Patients' Utilization

BACKGROUND

Research connecting patient-centered medical homes (PCMHs) with improved quality and reduced utilization is inconsistent, possibly because individual domains of change, and the stage of change, are not incorporated in the research design. The objective of this study was to examine the association between stage and domain of change and patterns of health care utilization.

METHODS

This was a cross-sectional observational study that including 87 Minnesota clinics certified as medical homes. Patients included those receiving management for diabetes or cardiovascular disease with insurance coverage by payers participating in the study. PCMH transformation stage was defined by practice systems in place, with measurements summarized in 5 domains. Health care utilization was measured by total utilization, frequency of outpatient visits and prescriptions, and occurrence of inpatient and emergency department visits.

RESULTS

PCMH transformation was associated with few changes in utilization, but there were important differences by the underlying domains of change. We demonstrate meaningful differences in the impact of PCMH transformation by diagnosis cohort and comorbidity status of the patient.

CONCLUSIONS

Because the association of health care utilization with PCMH transformation varied by transformation domain and patient diagnosis, practice leaders need to be supported by research incorporating detailed measures of PCMH transformation.

Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents

INTRODUCTION

Care by Design™ (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs).

METHODS

This was an observational time series before and after the implementation of CBD (Canada). Participants are LTCF residents with 911 Emergency Health Services calls from 10 LTCFs, representing 1424 beds. Data were abstracted from LTCF charts and Emergency Health Services databases. The primary outcome was ambulance transports from LTCFs to EDs. Secondary outcomes included access (primary care physician notes in charts) and continuity (physician numbers and contacts).

RESULTS

After implementation of CBD (Canada), transports from LTCFs to EDs were reduced by 36%, from 68 to 44 per month (P = .01). Relational and informational continuity of care improved with resident charts with ≥10 physician notes, increasing 38% before CBD to 55% after CBD (P = .003), and the median number of chart notes increased from 7 to 10 (P = .0026). Physicians contacted before 911 calls and onsite assessment increased from 38% to 54% (P = .01) and 3.7% to 9.2% (P = .03), respectively, before CBD to after CBD.

CONCLUSION

A 34% reduction in overall transports from LTCFs to EDs is likely attributable to improved onsite primary care, with consistent physician and team engagement and improvements in continuity of care.

Negative correlation between mycological surfaces pollution in hospital emergency departments and blood monocytes phagocytosis of healthcare workers

The aim of the present study was to find a possible relationship between the presence of yeast and filamentous fungi in hospital emergency departments and the activity levels of blood granulocytes and monocytes in emergency personnel. The study of mycological pollution was conducted in winter; the samples were collected from 10 Warsaw hospitals emergency departments (HE D) and in 10 control locations (office spaces) and included air samples and swabbing of floor and walls. The blood for immunological investigation was taken in spring, from 40 men, 26 to 53 years old, healthcare workers of these departments, who have been working for at least 5 years in their current positions, and from 36 corresponding controls, working in control offices. Evaluation of blood leukocyte subpopulations was done by hematological analyzer and cytometry analysis and monocyte and granulocyte phagocytosis by Phagotest. There were no significant differences in the level of mycological contamination between the test and control places. The qualitative analysis of the surfaces and air samples revealed a prevalence of strains belonging to Aspergillus spp. and Penicillium spp. genus. Statistical analysis revealed the existence of negative correlation between the number of phagocytizing blood monocytes and fungi spores content on floor and wall surfaces in hospital emergency departments (r = -0.3282, p < 0.05 and positive correlation between the number of phagocytizing monocytes in the blood of office workers and fungi pollution of control offices (r = 0.4421, p < 0.01).

Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments

BACKGROUND

The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear.

METHODS

Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010.

RESULTS

Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%).

CONCLUSIONS

Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

Examining Mental Health Act usage in an urban emergency department

OBJECTIVE

In this study we aimed to examine the characteristics of Mental Health Act (MHA) usage in the Emergency Department (ED) of an urban teaching hospital in Sydney.

METHODS

All MHA certificates written on individuals in the ED over a 12-week period in 2013 were collected. The medical record of each individual was reviewed by a member of the research team using an audit tool developed for the study. Any uncertainty over individual cases was addressed through research team consensus.

RESULTS

A total of 172 MHA certificates were collected; 67 were written by police, 45 by ambulance, 54 by medical officers and three by accredited persons. Three magistrate orders for assessment were also received. Seventy percent of police and 60% of ambulance MHA certificates did not result in admission. Over a third were revoked by ED physicians. Forty-five people (32.4%) who presented voluntarily were subsequently detained.

CONCLUSIONS

Police and ambulance MHA certification was a poor predictor of admission. Least restrictive measures were predominantly the outcome. Delegating ED physicians with authorised medical officer status assisted in facilitating this process. Formalised education and training on the principles and practicalities of MHA legislation should be ongoing for all professionals involved.

Recreational use, analysis and toxicity of tryptamines

The definition New psychoactive substances (NPS) refers to emerging drugs whose chemical structures are similar to other psychoactive compounds but not identical, representing a "legal" alternative to internationally controlled drugs. There are many categories of NPS, such as synthetic cannabinoids, synthetic cathinones, phenylethylamines, piperazines, ketamine derivatives and tryptamines. Tryptamines are naturally occurring compounds, which can derive from the amino acid tryptophan by several biosynthetic pathways: their structure is a combination of a benzene ring and a pyrrole ring, with the addition of a 2-carbon side chain. Tryptamines include serotonin and melatonin as well as other compounds known for their hallucinogenic properties, such as psilocybin in 'Magic mushrooms' and dimethyltryptamine (DMT) in Ayahuasca brews.

AIM

To review the scientific literature regarding tryptamines and their derivatives, providing a summary of all the available information about the structure of these compounds, their effects in relationship with the routes of administration, their pharmacology and toxicity, including articles reporting cases of death related to intake of these substances.

METHODS

A comprehensive review of the published scientific literature was performed, using also non peer-reviewed information sources, such as books, government publications and drug user web fora.

CONCLUSIONS

Information from Internet and from published scientific literature, organized in the way we proposed in this review, provides an effective tool for specialists facing the emerging NPS threat to public health and public security, including the personnel working in Emergency Department.

DELIBERATE SELF-HARM PATIENTS VISITING PUBLIC AND PRIVATE EMERGENCY DEPARTMENTS OF KARACHI

OBJECTIVE

To study the mode of attempted deliberate self-harm (DSH) in patients presenting to the Emergency Departments (ED) of public and private hospitals of Karachi, Pakistan.

DESIGN

A cross sectional study.

PLACE AND DURATION OF STUDY

Aga Khan University Hospital Karachi, Jinnah Post Graduate Medical Centre Karachi and Civil Hospital Karachi; March 2011 to February 2012.

SUBJECTS AND METHODS

One hundred DSH cases from ED of a private sector hospital were compared with 101 patients from two public sector hospitals.

RESULTS

DSH patients in the private hospital were mostly females (70%), had higher level of education (32%), did not share their problems (67%) with someone and had more mental disorders (28%). Patients from public hospitals were treated more for physical illnesses compared to private facility. Organophosphorus poisoning (90%) was a common mode of DSH in patients presenting to public hospitals; however significant number of organophosphorus poisoning (40%) was also seen in private hospital besides the benzodiazepine overdose (32%).

CONCLUSION

Emergency Physicians working in the EDs, both public and private sector hospitals of Karachi, should have adequate knowledge of managing organophosphorus poisoning. As more and more cases are presenting to the EDs, there should be a public health initiative to control the illegal sale and availability of such compounds in Pakistan.