Sistema de clasificación en emergencias - Escala canadiense de clasificación y severidad relacionado con aumento en fallecimientos en un hospital general / Emergency Classification System - CTAS is related to an increase in deaths in a tertiary hospital

Resumen Objetivo. El sistema de clasificación en servicios de emergencias fue implementado en todos los servicios de emergencias de la Caja Costarricense de Seguro Social alrededor del 2015, a pesar de que su utilidad y veracidad han sido cuestionadas. El presente estudio pretende establecer si existe una relación entre cambios en la cantidad de fallecimientos y en la mortalidad con la implementación de la Escala Canadiense de Clasificación y Severidad en los servicios de emergencias. Métodos. Se obtuvieron los registros correspondientes a las atenciones del Servicio de Emergencias del 2008 al 2022. Se realizó la comparación de los registros previos y posteriores a la implementación de la Escala Canadiense de Clasificación y Severidad en marzo del 2015. En total se tomaron en cuenta los datos referentes a 1 351 091 consultas, de las cuales 733 318 se dieron antes de la implementación de la escala canadiense de clasificación y severidad. Se compararon ambas poblaciones con respecto a tendencias temporales en fallecimientos, estancias en el servicio antes del fallecimiento, mortalidad y la relación entre fallecimientos y hora-paciente mensuales. Resultados. Se encontró un aumento significativo en los fallecimientos con la implementación de la Escala Canadiense de Clasificación y Severidad en un 19,8 % (p<0,001). La mortalidad en el servicio de emergencias mostró un aumento continuo desde el 2012. Sin embargo, una normalización del número de atenciones permitió observar un aumento de la mortalidad posterior, pero no previo a la implementación de la Escala Canadiense de Clasificación y Severidad (p<0,02). Por su parte, la cuantía de fallecimientos mensuales no ha mostrado relacionarse con cuantía de atenciones mensuales ni con hora-pacientes mensuales. Conclusión. La implementación de la Escala Canadiense de Clasificación y Severidad en el servicio de emergencias de un hospital de tercer nivel en Costa Rica se relacionó con un aumento en los fallecimientos, sin estar relacionado con indicadores de plétora del servicio.

Abstract Aim: The classification system in emergency rooms was implemented in all the emergency services of the Caja Costarricense de Seguro Social around 2015, despite the fact that its usefulness and veracity have been questioned. The present study aimed to establish changes in the number of deaths and in mortality with the implementation of the Canadian Triage and Severity Scale. Methods: The records corresponding to the attentions of the Emergency Service from 2008 to 2022 were obtained and comparisons were made of the records before and after the implementation of the Canadian Triage and Severity Scale in March 2015. In total, the data referring to 1,351,091 consultations were taken into account, of which 733,318 occurred before the implementation of the scale. Both populations were compared with respect to temporal trends in deaths, stays in the service before death, mortality, and the relationship between deaths and monthly patient-hours. Results: A significant increase in deaths was found after the implementation of the Canadian Triage and Severity Scale by 19.8% (p<0.001). Mortality showed a continuous increase since 2012, however a normalization of the number of visits allowed us to observe an increase in mortality after but not before the implementation of the scale (p<0.02). The number of monthly deaths has not been shown to be related to the amount of monthly consults or monthly patient-hours. Conclusions: The implementation of the Canadian Triage and Severity Scale in the emergency room of a third level hospital in Costa Rica was related in the present study to an increase in deaths, without being related to indicators of service plethora.

Medical imaging call centre: a communication success story.

AIM: To evaluate utilisation of a medical imaging call centre (MICC) at a multi-site, academic radiology department, focusing on communication of critical, urgent, or significant unexpected findings. MATERIALS AND METHODS: Institutional research ethics board approval was obtained. All calls made to MICC from 1 January to 31 December 2019 were reviewed retrospectively. The total number of calls, date, and reason of each call, level of report alert, and turnaround time (TAT) were recorded. Level 1, 2, and 3 alerts were defined as "potentially life-threatening new/unexpected findings", "could result in morbidity/mortality", or "not immediately life-threatening or urgent", respectively. TAT was defined as the time from alert request received by the MICC until acknowledgement of receipt by the referring physician, with a desired TAT of 60 min, 3 h, and 3 days for each level, respectively. RESULTS: The MICC received 29,799 calls in 2019, on average 2,483 (range 1,989-3,098) calls per month. The most common indications for contacting the MICC were to request imaging reports to be expedited (14,916 calls, 50%) and issuing report alerts to communicate unexpected or urgent findings (7,060 calls, 24%). Average number and range of calls for Level 1, 2, and 3 alerts were 57 (39-80), 345 (307-388), and 187 (127-215) per month, respectively. Average TAT for Level 1, 2, and 3 report alerts were 59 min, 2 h 26 min, and 19 h 39 min, respectively. CONCLUSION: The MICC received a large volume of calls and was a successful method for timely communication of unexpected or urgent imaging findings using a three-tiered alert system.

Factors Associated with Emergency Department Length of Stay in Critically Ill Patients: A Single-Center Retrospective Study.

BACKGROUND Length of stay (LOS) in the emergency department (ED) should be measured and evaluated comprehensively as an important indicator of hospital emergency service. In this study, we aimed to analyze clinical characteristics of critically ill patients admitted to the ED and identify the factors associated with LOS. MATERIAL AND METHODS All patients with level 1 and level 2 of the Emergency Severity Index who were admitted to the ED from January 2018 to December 2019 were included in this retrospective study. The patients were divided into 2 groups: LOS ≥4 h and LOS <4 h. Variables were comprehensively analyzed and compared between the 2 groups. RESULTS A total of 19 616 patients, including 7269 patients in the LOS ≥4 h group and 12 347 patients in the LOS <4 group, were included. Advanced age, admission in winter and during the night shift, and diseases excluding nervous system diseases, cardiovascular diseases, and trauma were associated with higher risk of LOS. Nervous system diseases, cardiovascular diseases, trauma, and procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis were associated with lower risk of LOS. CONCLUSIONS Prolonged LOS in the ED was associated with increased age and admission in winter and during the night shift, while shortened LOS was associated with nervous system diseases, cardiovascular diseases, and trauma, as well as with procedures including tracheal intubation, surgery, percutaneous coronary intervention, and thrombolysis. Our findings can serve as a guide for ED physicians to individually evaluate patient condition and allocate medical resources more effectively.

EUAdb: A resource for COVID-19 test development and comparison.

Due to the sheer number of COVID-19 (coronavirus disease 2019) cases there is a need for increased world-wide SARS-CoV-2 testing capability that is both efficient and effective. Having open and easy access to detailed information about these tests, their sensitivity, the types of samples they use, etc. would be highly useful to ensure their reproducibility, to help clients compare and decide which tests would be best suited for their applications, and to avoid costs of reinventing similar or identical tests. Additionally, this resource would provide a means of comparing the many innovative diagnostic tools that are currently being developed in order to provide a foundation of technologies and methods for the rapid development and deployment of tests for future emerging diseases. Such a resource might thus help to avert the delays in testing and screening that was observed in the early stages of the pandemic and plausibly led to more COVID-19-related deaths than necessary. We aim to address these needs via a relational database containing standardized ontology and curated data about COVID-19 diagnostic tests that have been granted Emergency Use Authorizations (EUAs) by the FDA (US Food and Drug Administration). Simple queries of this actively growing database demonstrate considerable variation among these tests with respect to sensitivity (limits of detection, LoD), controls and targets used, criteria used for calling results, sample types, reagents and instruments, and quality and amount of information provided.

Referral for investigation: a redundant SNOMED-CT chief presenting complaint.

AIM: The Ministry of Health has mandated that all emergency department (ED) presentations are coded using the Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) from 2021. The current ED reference set contains the non-specific term 'Referral for investigation' in the list of available chief presenting complaints (CPCs). The aim of this study was to determine the rate of use of this term and how often a more specific (and therefore more clinically useful) term was used. METHOD: This was a cross-sectional audit of routinely collected presenting complaint data, supplemented by a retrospective case note review. RESULTS: 'Referral for investigation' was used for 497/9,067 (5.5%, 95%CI 5-6%) presentations, with increased use for urgent cases. An alternative CPC was available in 467/497 (94.0%, 95%CI 92-96%) of cases from the existing reference set. Of 98 different CPCs, the common alternatives were: 'Chest pain' (6.4%), 'Shortness of breath' (4.2%) 'Abdominal pain' (3.6%), 'Altered mental status' (3.4%) and 'Postoperative complication' (3.2%). Six of 13 cardiac arrests and eight of 63 of multiple trauma cases were coded as 'Referral for investigation'. With the addition of two new terms to the New Zealand reference set ('Abnormal blood test' and 'Radiology request'), each of the remaining 30 presentations would have an alternative and more accurate CPC. CONCLUSION: 'Referral for investigation' should be removed from the New Zealand emergency department reference set for chief presenting complaints to improve data quality.

A COVID-19 screening tool for oncology telephone triage.

PURPOSE: Symptoms associated with COVID-19 infection have made the assessment and triage of cancer patients extremely complicated. The purpose of this paper is to describe the development and implementation of a COVID-19 screening tool for oncology telephone triage. METHODS: An Ambulatory Oncology Clinical Nurse Educator and three faculty members worked on the development of an oncology specific triage tool based on the challenges that oncology nurses were having with the generic COVID triage tool. A thorough search of the published literature, as well as pertinent websites, verified that no screening tool for oncology patients was available. RESULTS: The screening tool met a number of essential criteria: (1) simple and easy to use, (2) included the most common signs and symptoms as knowledge of COVID-19 infection changed, (3) was congruent with the overall screening procedures of the medical center, (4) included questions about risk factors for and environmental exposures related to COVID-19, and (5) assessed patient's current cancer history and treatment status. Over a period of 3 weeks, the content and specific questions on the tool were modified based on information obtained from a variety of sources and feedback from the triage nurses. CONCLUSION: Within 1 month, the tool was developed and implemented in clinical practice. Oncology clinicians can modify this tool to triage patients as well as to screen patients in a variety of outpatient settings (e.g., chemotherapy infusion units, radiation therapy departments). The tool will require updates and modifications based on available resources and individual health care organizations' policies and procedures.

Psychiatric emergencies during the height of the COVID-19 pandemic in the suburban New York City area.

BACKGROUND: This report characterizes patients presenting for psychiatric emergencies during the COVID-19 pandemic and describes COVID-19-related stressors. METHODS: Patients seen for emergency psychiatric evaluation during the height of the COVID-19 period (March 1-April 30, 2020; N = 201) were compared with those in the immediate Pre-COVID-19 period (January 1-February 28, 2020; N = 355), on sociodemographic characteristics, psychiatric diagnoses, symptoms, and disposition. Patients tested positive for COVID-19 were compared with those that tested negative on the same outcomes. Prevalence and nature of COVID-19-stressors that influenced the emergency presentation were rated. OUTCOME: The most common psychiatric diagnoses and presenting symptoms during both periods were depression and suicidal ideation. Comparing the Pre-COVID-19 and COVID-19 periods, a significant decline in emergency psychiatric volume was observed in children and adolescents (C/A), but not adults. COVID-19 period C/A patients had more new onset disorders and were more likely to be admitted to inpatient care, but were less likely to present with suicide attempts, impulse control disorders and agitation/aggression. Adults were more likely to have no access to outpatient care, present with anxiety disorders, and were also more likely to be admitted for inpatient care. COVID-19 directly affected the psychiatric emergency in 25% of patients, with the more severe stressors triggered by fear of COVID infection (including psychosis), actual COVID infection in self or family members, including death of a loved one. COVID-positive patients were more likely to have psychosis, including new-onset, and were less likely to be depressed/suicidal compared to their COVID-negative counterparts. CONCLUSION: This report demonstrates the need for emergency psychiatric services throughout the COVID-19 pandemic and the need for clinical and diagnostic COVID-19 screening of psychiatric emergency patients. New and severe pathology underscore the need for enhanced outpatient access to tele-mental health, crisis hotline and on-line psychotherapeutic services, as well as psychiatric inpatient services with capacity to safely care for COVID-19 patients.

Accuracy of SNOMED-CT Chief Presenting Complaint Codes: an audit of 1,000 cases.

AIM: The Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) coding system has been introduced to emergency departments in New Zealand, starting with the patient's chief presenting complaint (CPC). However, it is not known how accurate CPC coding at triage is, or whether coding accuracy varies by patient characteristics. The aim of this study was to determine the accuracy of CPC coding. METHOD: We compared the real-time triage recorded CPC with the presenting complaints recorded in medical notes by the treating clinician. Agreement was determined by exact CPC matches and the kappa statistic. RESULTS: From 1,000 consecutive presentations 852 were eligible (89 CPCs). Real-time CPC agreed with clinical notes in 514/852 (60.3%) cases. When real-time free text comments were included, agreement was 732/852 (85.9%). There were no differences by age, sex or ethnicity. Agreement for the common CPCs: 'trauma' (21%); 'abdominal pain' (11%), 'chest pain' 87 (10%) and 'shortness of breath' (8%) was substantial, k=0.66 (95% CI: 0.61, 0.70). Use of non-specific CPC such as 'referral for investigation' (5%) and 'general weakness/fatigue/unwell' (2%) was uncommon but associated with poor agreement. CONCLUSION: The accuracy of real-time coding for CPC using SNOMED-CT was reasonable, except for non-specific CPCs, which should be avoided where possible.

Imaging Cardiovascular Emergencies: Real World Clinical Cases.

Cardiovascular emergencies represent life-threatening conditions requiring a high index of clinical suspicion. In an emergency scenario, a simple stepwise biomarker/imaging diagnostic algorithm may help prompt diagnosis and timely treatment along with related improved outcomes. This article describes several clinical cases of cardiovascular emergencies, such as coronary stent thrombosis-restenosis, takotsubo syndrome, acute myocarditis, massive pulmonary embolism, type A acute aortic dissection, cardiac tamponade, and endocarditis.

Characterization of In-Flight Medical Events Involving Children on Commercial Airline Flights.

STUDY OBJECTIVE: More than 4 billion passengers travel on commercial airline flights yearly. Although in-flight medical events involving adult passengers have been well characterized, data describing those affecting children are lacking. This study seeks to characterize pediatric in-flight medical events and their immediate outcomes, using a worldwide sample. METHODS: We reviewed the records of all in-flight medical events from January 1, 2015, to October 31, 2016, involving children younger than 19 years treated in consultation with a ground-based medical support center providing medical support to 77 commercial airlines worldwide. We characterized these in-flight medical events and determined factors associated with the need for additional care at destination or aircraft diversion. RESULTS: From a total of 75,587 in-flight medical events, we identified 11,719 (15.5%) involving children. Most in-flight medical events occurred on long-haul flights (76.1%), and 14% involved lap infants. In-flight care was generally provided by crew members only (88.6%), and physician (8.7%) or nurse (2.1%) passenger volunteers. Most in-flight medical events were resolved in flight (82.9%), whereas 16.5% required additional care on landing, and 0.5% led to aircraft diversion. The most common diagnostic categories were nausea or vomiting (33.9%), fever or chills (22.2%), and acute allergic reaction (5.5%). Events involving lap infants, syncope, seizures, burns, dyspnea, blunt trauma, lacerations, or congenital heart disease; those requiring the assistance of a volunteer medical provider; or those requiring the use of oxygen were positively correlated with the need for additional care after disembarkment. CONCLUSION: Most pediatric in-flight medical events are resolved in flight, and very few lead to aircraft diversion, yet 1 in 6 cases requires additional care.

How Well Planned Urgency Class Come True in The Emergency Surgery? Timing of Acute Care Surgery.

BACKGROUND AND AIMS: Emergency surgery represents an essential aspect of surgical care, but little is known about realization of the planned emergency class. Different systems such as NCEPOD classification and Timing of Acute Care Surgery classification have been developed for the timing of the emergency surgery. The aim of the study was to find out how well planned urgency class is being implemented. MATERIALS AND METHODS: The planned and realized waiting times for all emergency surgeries were studied during the 6-month period in the Oulu University Hospital. The catchment area of the hospital includes a population of 742,000. The urgency in the hospital is planned in a four-step scale: an extremely urgent (E) patient should be taken immediately to the operating theater. Class I urgency surgery should start within 3 h (180 min), class II within 8 h (480 min), and class III within 24 h (1440 min). Surgeon plans urgency at his discretion, and no specific urgency has been imposed on certain diagnoses thus the surgeon's perceptions of the illness or trauma affects the assessment. RESULTS: Extreme urgent patients had an average waiting time of 26 min. For class I patient, the average waiting time was 59 min, while 93% of surgeries were started within the target time. For class II and class III patients, these figures were 337 min and 86% and 830 min and 78%, respectively. CONCLUSION: With regard to urgency, the higher the degree of urgency, the greater the chance of the surgery being realized within the planned time.

Embracement with risk classification: relationship of justice with the user / Acogida con clasificación de riesgo: relación de justicia con el usuario / Acolhimento com classificação de risco: relação de justiça com o usuário

ABSTRACT Objective: to describe the conception of justice of nurses and users regarding the Risk Classification in Emergency Unit; to analyze the conception of justice in the implementation of the Risk Classification in Emergency Unit from the user's recognition; to discuss, from Axel Honneth's Theory of Recognition, justice with the user in the Risk Classification in Emergency Unit. Method: qualitative research of descriptive, exploratory typology, which used action research as a method. Bardin's Content Analysis was carried out. Results: a category was created: "Justice versus Injustice" and three subcategories: "Autonomy/Freedom versus Heteronomy/Subordination"; "Communication versus Hermeneutic Problems"; "Contributions versus Conflicts". Final considerations: Embracement with Risk Classification presents difficulties in its interpretation and effectiveness; there are situations of disrespect that compete against the required ethics. Justice addressed by this study will be achieved by an emergency access system that meets user expectations, recognizing it as a subject of rights.

RESUMEN Objetivo: describir la concepción de justicia de enfermeros y usuarios en la Clasificación de Riesgo en Emergencia; analizar la concepción de justicia en la implementación de la Clasificación de Riesgo en la Emergencia a partir del reconocimiento del usuario; discutir, a partir de la Teoría del Reconocimiento de Axel Honneth, la justicia con el usuario en la Clasificación de Riesgo en Unidad de Emergencia. Método: investigación cualitativa de tipología descriptiva, exploratoria, que utilizó como método la investigación-acción. Análisis de Contenido de Bardin. Resultados: se organizó una categoría: "Justicia versus Injusticia" y tres subcategorías: "Autonomía/Libertad versus Heteronomía/Subordinación"; "Comunicación versus Problemas Hermenéuticos"; "Contribuciones versus Conflictos". Consideraciones finales: Acogida con Clasificación de Riesgo presenta dificultades en su interpretación y efectividad, con situaciones de incumplimiento que concurren contra la ética requerida. La justicia de que trata este estudio será alcanzada por un sistema de acceso a las emergencias que alcance las expectativas del usuario, reconociéndolo como sujeto de derechos.

RESUMO Objetivo: descrever a concepção de justiça de enfermeiros e usuários na Classificação de Risco em Emergência; analisar a concepção de justiça na implementação da Classificação de Risco na Emergência a partir do reconhecimento do usuário; discutir, a partir da Teoria do Reconhecimento de Axel Honneth, a justiça com o usuário na Classificação de Risco em Unidade de Emergência. Método: pesquisa qualitativa de tipologia descritiva, exploratória, que utilizou como método a pesquisa-ação. Análise de Conteúdo de Bardin. Resultados: foi organizada uma categoria: "Justiça versus Injustiça" e três subcategorias: "Autonomia/Liberdade versus Heteronomia/Subordinação"; "Comunicação versus Problemas Hermenêuticos"; "Contribuições versus Conflitos". Considerações finais: o Acolhimento com Classificação de Risco apresenta dificuldades em sua interpretação e efetividade, com situações de desrespeito que concorrem contra a ética requerida. A justiça de que trata esse estudo será alcançada por um sistema de acesso às emergências que atinja as expectativas do usuário, reconhecendo-o como sujeito de direitos.

Embracement with risk classification: relationship of justice with the user.

OBJECTIVE: to describe the conception of justice of nurses and users regarding the Risk Classification in Emergency Unit; to analyze the conception of justice in the implementation of the Risk Classification in Emergency Unit from the user's recognition; to discuss, from Axel Honneth's Theory of Recognition, justice with the user in the Risk Classification in Emergency Unit. METHOD: qualitative research of descriptive, exploratory typology, which used action research as a method. Bardin's Content Analysis was carried out. RESULTS: a category was created: "Justice versus Injustice" and three subcategories: "Autonomy/Freedom versus Heteronomy/Subordination"; "Communication versus Hermeneutic Problems"; "Contributions versus Conflicts". FINAL CONSIDERATIONS: Embracement with Risk Classification presents difficulties in its interpretation and effectiveness; there are situations of disrespect that compete against the required ethics. Justice addressed by this study will be achieved by an emergency access system that meets user expectations, recognizing it as a subject of rights.

Circulatory emergencies in the delivery room.

The transition from fetal to neonatal life is a dramatic and complex process involving extensive physiologic changes, which are most obvious at the time of birth. Individuals who care for newly born infants must monitor the progress of the transition and be prepared to intervene when necessary. In the majority of births, this transition occurs without a requirement for any significant assistance. If newborns require assistance, the majority of the time respiratory support is all that is required. In some instances, however, there are circulatory emergencies that need to be rapidly identified or there may be dire consequences including death in the delivery room. This chapter will review various pathologies that are circulatory emergencies, and discuss how to assess them. We will also review new technologies which may help providers better understand the circulatory status or hemodynamic changes in the delivery room including heart rate, cardiac output, cerebral oxygenation and echocardiography.

Resources spent on dermatological emergency patients: A twelve-month prospective data collection from Germany.

BACKGROUND AND OBJECTIVES: Rising numbers of patients consulting emergency units are associated with an increased demand for material and personnel. In order to better quantify these resources, we performed an analysis of diagnostic procedures, treatment types, and the quantity and educational level of staff involved in emergency consultations. PATIENTS AND METHODS: The study was conducted as a prospective single-center survey over twelve months in the dermatology unit of a Germany university hospital. 3155 consultations were included by consecutive sampling. RESULTS: Diagnostic tests (e.g. microbiological swab, blood testing, punch biopsy) were performed in 29 % of all consultations. Physicians prescribed treatment in 70 % of cases, with steroids and antihistamines being the most frequent topical and systemic treatment, respectively. Each patient was seen by at least one physician and a nurse, and in 25 % of cases an additional physician was involved. Less than thirty minutes was required for the consultation in the vast majority of cases. On average, emergency consultations required two hours per day of the treating physician's time, not including the time of other involved staff such as nurses and laboratory technicians. CONCLUSIONS: This study demonstrates the extent of resources involved in the treatment of dermatological emergency consultations.

Patient-initiated emergency department visits without primary care follow-up: frequency and characteristics. / Atenciones en urgencias a demanda del paciente sin seguimiento posterior en atención primaria: frecuencia y características.

OBJECTIVES: To estimate the volume of patient-initiated visits to the emergency department without follow-up by a primary care physician, and to identify factors related to this practice. MATERIAL AND METHODS: Retrospective, observational study of patients attended in a tertiary care hospital emergency department. We used a cluster/systematic sampling method to select 0.05% of the episodes discharged home every month. The following data were extracted: demographic variables, care times, prior primary care for the same episode, triage level, diagnosis, cost of prescriptions on discharge, instructions for follow-up, and adherence to those instructions. Associations were explored using multivariate logistic regression modelling. RESULTS: A total of 1277 episodes were analyzed; 48.1% were patient-initiated visits without primary care follow-up. These visits were associated with the following variables: young patients (P = .002) without prior primary care (odds ratio [OR], 1.74; 95% CI, 1.34-2.28); visits between 10 PM and 4 AM (OR, 2.43; 95% CI, 1.55-3.80); triage level 4-5 (OR, 1.33; 95% CI, 1.04-1.69); ophthalmologic emergency (OR, 1.64; 95% CI, 1.12-2.41); a prescription cost of less than €3 (OR, 2.39; 95% CI, 1.87-3.06); and instruction to seek follow-up on discharge (OR, 1.9; 95% CI, 1.37-2.65). CONCLUSION: Half of patients who independently seek care from the emergency department and are discharged home do not later seek care at their primary care clinic. The emergency physician should insist on the importance of ongoing primary care.

OBJETIVO: Cuantificar los episodios asistenciales del servicio de urgencias originados a iniciativa del paciente sin seguimiento posterior en atención pimaria (EIPSS), e identificar factores asociados a ello. METODO: Estudio retrospectivo observacional de pacientes atendidos en Urgencias de un hospital de tercer nivel durante 2 años, mediante muestreo sistemático por conglomerados correspondiente al 0,05% de los episodios de cada mes, con alta a domicilio. Se analizaron variables demográficas, tiempos asistenciales, abordaje previo en atención primaria por el mismo episodio (APAP), nivel de triaje, diagnóstico, importe de la prescripción al alta e indicación de seguimiento y realización del mismo. Se utilizó un modelo multivariante de regresión logística para la estimación del grado de asociación. RESULTADOS: Se analizaron 1.277 episodios, encontrándose un EIPSS en el 48,1% de ellos. Estos fueron más frecuentes entre los más jóvenes (p = 0,002), sin APAP (OR: 1,74; IC 95% 1,34-2,28), en los que accedieron de 22-04 h (OR: 2,43; IC 95%: 1,55-3,80%), con un nivel de triaje 4-5 (OR: 1,33; IC 95%: 1,04-1,69), con una urgencia oftalmológica como motivo de consulta (OR: 1,64; IC 95%: 1,12-2,41), con un coste de la prescripción menor de 3 € (OR: 2,39; IC 95%: 1,87-3,06) y en quienes fue indicado seguimiento al alta (OR: 1,9; IC 95%: 1,37-2,65). CONCLUSIONES: La mitad de los pacientes que acuden por iniciativa propia al SUH y se van de alta a domicilio no realizan seguimiento posterior por atención primaria (AP). En este grupo de pacientes, el urgenciólogo debería insistir en la importancia de la asistencia previa y posterior por AP.

Suitability of the German version of the Manchester Triage System to redirect emergency department patients to general practitioner care: a prospective cohort study.

OBJECTIVES: To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany. DESIGN: Prospective cohort study. SETTING: Single centre University Hospital Emergency Department. PARTICIPANTS: Adult, non-surgical ED patients. EXPOSURE: A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS. PRIMARY AND SECONDARY OUTCOME MEASURES: Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality). RESULTS: A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420). CONCLUSIONS: The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care. TRIAL REGISTRATION NUMBER: U1111-1119-7564; Post-results.

Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study.

OBJECTIVE: Video laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes' (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh) as emergency tracheal intubations (TIs) reference. DESIGN: Retrospective cohort study. SETTING: The emergency department (ED) and the intensive care unit (ICU) of two Japanese tertiary-level hospitals. PARTICIPANTS: All consecutive video-recorded emergency TI cases in EDs and ICUs between December 2013 and June 2015. PRIMARY OUTCOME MEASURES: The primary study endpoint was first-pass intubation success. A subgroup analysis examined the first-pass intubation success of expert versus non-expert operators. A logistic regression analysis was performed to identify the predictors of first-pass intubation success. RESULTS: A total of 287 emergency TIs were included. The first-pass intubation success rates were 78%, 58%, 78% and 58% for the Pentax, King, McGrath and Macintosh instruments, respectively (p=0.004, Fisher's exact test). The non-expert operators' success rates were significantly higher (p=0.00004, Fisher's exact test) for the Pentax (87%) and McGrath (78%) instruments than that for the King (50%) and Macintosh (46%) instruments, unlike that of the experts (67%, 67%, 78% and 78% for Pentax, McGrath, King and Macintosh, respectively; p=0.556, Fisher's exact test). After TI indication, difficult airway characteristics, and expert versus non-expert operator parameters adjustments, the Pentax (OR=3.422, 95% CI 1.551 to 7.550; p=0.002) and McGrath (OR= 3.758, CI 1.640 to 8.612; p=0.002) instruments showed significantly higher first-pass intubation success odds when compared with the Macintosh laryngoscope (reference, OR=1). The King instrument, however, (OR=1.056; 95% CI 0.487 to 2.289, p=0.889) failed to show any significant superiority. CONCLUSION: The Pentax and McGrath laryngoscopes showed significantly higher emergency TI first-pass intubation success rates than the King laryngoscope when compared with the Macintosh laryngoscope, especially for non-expert operators. TRIAL REGISTRATION NUMBER: UMIN000027925; Results.

[Skin-to-skin during caesarean section: Assessment of professional practices]. / Le peau à peau du nouveau-né en cours de césarienne : une étude d'évaluation des pratiques professionnelles.

BACKGROUND: Considering its benefits, immediate skin-to-skin should be applied irrespective of the way of delivery. While it is increasingly applied in case of vaginal delivery, it remains difficult to implement in case of caesarean section. OBJECTIVE: To estimate the degree of implementation of skin-to-skin in case of caesarean section. METHODS: Survey in immediate postpartum with a continuous series of patients having given birth by caesarean - whether scheduled or not - in a level 3 hospital systematically realizing skin-to-skin in case of vaginal delivery. The patients were included if the caesarean section had been realized between 16/11/17 and 28/11/17. RESULTS: Thirty-five women gave birth by caesarean section during the period of study, among which 26 were planned (74%). The emergency levels were varied: 18 had a green code (51%), 12 an orange code (34%) and 5 a red code (14%). Forty-six percent of the newborn children were placed skin-to-skin. The frequency of skin-to-skin was closely linked to the planned character of the caesarean section (89 vs. 31%, P=0.005), as well as its color code (green 72%, orange 25%, red 0%). In case of impossibility to realize skin-to-skin in the course of the caesarean, the reasons were mainly related to the maternal state (63%) (malaise, bleeding, pain). In this situation, skin-to-skin was proposed to the spouse in 83% of cases and realized in recovery room with the mother in 82% of the cases. CONCLUSION: Skin-to-skin is feasible during caesarean section, regardless of the color code of the procedure.