Does the Initial Screening of Syncope in the Emergency Department and During Hospitalization Adhere to ESC Guidelines?

BACKGROUND: The evaluation of syncope in emergency departments (EDs) and during hospitalization can be ineffective. The European Society of Cardiology (ESC) guidelines were established to perform the evaluation based on risk stratification. OBJECTIVES: To investigate whether the initial screening of syncope adheres to the recent ESC guidelines. METHODS: Patients with syncope who were evaluated in our ED were included in the study and retrospectively classified based on whether they were treated according to ESC guidelines. Patients were divided into two groups according to the ESC guideline risk profile: high risk or low risk. RESULTS: The study included 114 patients (age 50.6 ± 21.9 years, 43% females); 74 (64.9%) had neurally mediated syncope, 11 (9.65%) had cardiac syncope, and 29 (25.45%) had an unknown cause. The low-risk group included 70 patients (61.4%), and the high-risk group included 44 (38.6%). Only 48 patients (42.1%) were evaluated according to the ESC guidelines. In fact, 22 (36.7%) of 60 hospitalizations and 41 (53.2%) of 77 head computed tomography (CT) scans were not mandatory according to guidelines. The rate of unnecessary CT scans (67.3% vs. 28.6%, respectively, P = 0.001) and unnecessary hospitalization (66.7% vs. 6.7%, respectively, P < 0.02) were higher among low-risk patients than high-risk patients. Overall, a higher percentage of high-risk patients were treated according to guidelines compared to low-risk patients (68.2% vs. 25.7% respectively, P < 0.0001). CONCLUSIONS: Most syncope patients, particularly those with a low-risk profile, were not evaluated in accordance with the ESC guidelines.

Speckled Tracking of Pleura-A Novel Tool for Lung Ultrasound; Distinguishing COVID-19 from Acute Heart Failure.

For the acutely dyspneic patient, discerning bedside between acute decompensated heart failure (ADHF) and COVID-19 is crucial. A lung ultrasound (LUS) is sensitive for detecting these conditions, but not in distinguishing between them; both have bilateral B-lines. The Blue protocol uses pleural sliding to differentiate decreased pneumonia; however, this is not the case in ADHF. Nonetheless, this pleural sliding has never been quantified. Speckled tracking is a technology utilized in the echocardiography field that quantifies the motion of tissues by examining the movement of ultrasound speckles. We conducted a retrospective study of LUS performed in emergency room patients during the COVID-19 pandemic. Speckled tracking of the pleura by applying software to the B-mode of pleura was compared between COVID-19 patients, ADHF patients, and patients with no respiratory complaints. A significant difference was found between the patient groups on speckled tracking both in respect of displacement and velocity. ADHF had the highest displacement, followed by COVID-19, and then non-respiratory patients: 1.63 ± 1.89, 0.59 ± 0.71, and 0.24 ± 0.45, respectively (p < 0.01). A similar trend was seen in velocity with ADHF having the highest velocity 0.34 ± 0.37, followed by COVID-19 0.14 ± 0.71, and non-respiratory patients 0.02 ± 0.09 (p <0.01). Speckled tracking of the pleura is a potential tool for discerning between different causes of dyspnea.

Lean six sigma and stroke in rural hospital - The case of Baruch Padeh Medical Center.

PURPOSE: This case study aims to demonstrate the strengths of the Lean Six Sigma (LSS) methodology to improve the acute ischemic stroke (AIS) treatment rates and reduce process lead time at Baruch Padeh Medical Center (BPMC), a rural hospital in the Galilee region of Northern Israel. The LSS project redefined the BPMC stroke care pathway and increased its efficacy. DESIGN/METHODOLOGY/APPROACH: The LSS methodology was implemented in September 2017 by integrating lean principles and the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control). Existing procedures, field observation, ad hoc measurement and in-depth interviews were utilized, and the GEMBA method was implemented to identify root cause and improve actions optimizing the stroke pathway. FINDINGS: The presented case shows the usefulness of the LSS methodology in improving quality performance in a rural hospital. The intervention allowed the BPMC to improve the intravenous tissue plasminogen activator (IV-tPA) administration rate (+15.2%), reducing the process lead time. The lead time of door-to-computer tomography decreased from 52 to 26 min, and the door-to-needle time decreased from 94 to 75 min. ORIGINALITY/VALUE: The present case study shows the implementation of the LSS methodology aimed to improve the IV-tPA administration rate and reduce the stroke pathway lead time in a rural hospital. The case demonstrates the potential for the LSS methodology to support the AIS pathway optimization and represents a guide for healthcare organizations located in rural areas.

Ultrasound of Jugular Veins for Assessment of Acute Dyspnea in Emergency Departments and for the Assessment of Acute Heart Failure.

BACKGROUND: When a patient arrives at the emergency department (ED) presenting with symptoms of acute decompensated heart failure (ADHF), it is possible to reach a definitive diagnosis through many different venues, including medical history, physical examination, echocardiography, chest X-ray, and B-type natriuretic peptide (BNP) levels. Point-of-care ultrasound (POCUS) has become a mainstream tool for diagnosis and treatment in the field of emergency medicine, as well as in various other departments in the hospital setting. Currently, the main methods of diagnosis of ADHF using POCUS are pleural B-lines and inferior vena cava (IVC) width and respiratory variation. OBJECTIVES: To examine the potential use and benefits of bedside ultrasound of the jugular veins in the evaluation of dyspneic patients for identification of ADHF. METHODS: A blood BNP level was drawn from each participant at time of recruitment. The area and size of the internal jugular vein (IJV) during inspiration and expiration were examined. RESULTS: Our results showed that the respiratory area change of the IJVs had a specificity and sensitivity of nearly 70% accuracy rate in indentifying ADHF in our ED. CONCLUSIONS: Ultrasound of the IJV may be a useful tool for the diagnosis of ADHF because it is easy to measure and requires little skill. It is also not affected by patient body habitus.

Case Report: Infectious Diseases in Pilgrims Visiting the Holy Land.

Every year Christian pilgrims from around the world visit the holy sites located around the Sea of Galilee. Some become ill during their stay with infectious diseases that were acquired in their country of origin, and are hospitalized at Poriya Medical Center. They pose a diagnostic challenge due to language barriers, the rarity of these infections in Israel, and the fact that diagnostic tests are not readily available. All patient records from 2015 of Holy Land tourists hospitalized at Poriya Medical Center were screened for the diagnosis of imported zoonotic diseases that are not commonly diagnosed in Israel. Three patients who were on a Holy Land tour were hospitalized during 2015 with laboratory-confirmed diagnostically challenging zoonotic infectious diseases: a 91-year-old priest from Ethiopia diagnosed with relapsing fever due to Borrelia recurrentis, an 85-year-old retired mountaineer from New Hampshire diagnosed with human granulocytic anaplasmosis, and a 57-year-old farmer from central Brazil diagnosed with leptospirosis. These case reports emphasize the importance of considering imported zoonotic infectious diseases and obtaining appropriate diagnostic tests when treating Holy Land travelers to Israel.