Assessing Barriers and Facilitators to Participation in a Nurse-Driven, Opt-Out HIV Screening Program in the Emergency Department.

Emergency department (ED) HIV screening is a key component of the strategy to end the HIV epidemic, reaching populations with limited access to care for screening and early diagnosis. Many screening programs rely primarily on participation from ED nurses; however, little is known about the factors affecting nurse participation in screening. Guided by the Consolidated Framework for Implementation Research, 20 semi-structured interviews were conducted with ED nurses to explore perceptions of HIV screening, barriers and facilitators to participation, and implementation insights. Nurses were categorized as either high adopters or low adopters based on the number of HIV tests ordered 3 months prior to interviews. The Stanford Lightning Report Method, a rapid qualitative analysis approach, was used to analyze field notes. All participants generally agreed that the ED was an appropriate location for screening and that frequent, multimodal education about screening was needed. Integration of screening into standard workflows, education about the public health impact of screening, and the use of peer champions and mentors were identified as important strategies to increase participation. By incorporating these findings into implementation strategies, EDs may be able to increase nurse participation in screening, addressing important health equity issues in HIV diagnosis.

Accuracy of Prospective Assessments of 4 Large Language Model Chatbot Responses to Patient Questions About Emergency Care: Experimental Comparative Study.

BACKGROUND: Recent surveys indicate that 48% of consumers actively use generative artificial intelligence (AI) for health-related inquiries. Despite widespread adoption and the potential to improve health care access, scant research examines the performance of AI chatbot responses regarding emergency care advice. OBJECTIVE: We assessed the quality of AI chatbot responses to common emergency care questions. We sought to determine qualitative differences in responses from 4 free-access AI chatbots, for 10 different serious and benign emergency conditions. METHODS: We created 10 emergency care questions that we fed into the free-access versions of ChatGPT 3.5 (OpenAI), Google Bard, Bing AI Chat (Microsoft), and Claude AI (Anthropic) on November 26, 2023. Each response was graded by 5 board-certified emergency medicine (EM) faculty for 8 domains of percentage accuracy, presence of dangerous information, factual accuracy, clarity, completeness, understandability, source reliability, and source relevancy. We determined the correct, complete response to the 10 questions from reputable and scholarly emergency medical references. These were compiled by an EM resident physician. For the readability of the chatbot responses, we used the Flesch-Kincaid Grade Level of each response from readability statistics embedded in Microsoft Word. Differences between chatbots were determined by the chi-square test. RESULTS: Each of the 4 chatbots' responses to the 10 clinical questions were scored across 8 domains by 5 EM faculty, for 400 assessments for each chatbot. Together, the 4 chatbots had the best performance in clarity and understandability (both 85%), intermediate performance in accuracy and completeness (both 50%), and poor performance (10%) for source relevance and reliability (mostly unreported). Chatbots contained dangerous information in 5% to 35% of responses, with no statistical difference between chatbots on this metric (P=.24). ChatGPT, Google Bard, and Claud AI had similar performances across 6 out of 8 domains. Only Bing AI performed better with more identified or relevant sources (40%; the others had 0%-10%). Flesch-Kincaid Reading level was 7.7-8.9 grade for all chatbots, except ChatGPT at 10.8, which were all too advanced for average emergency patients. Responses included both dangerous (eg, starting cardiopulmonary resuscitation with no pulse check) and generally inappropriate advice (eg, loosening the collar to improve breathing without evidence of airway compromise). CONCLUSIONS: AI chatbots, though ubiquitous, have significant deficiencies in EM patient advice, despite relatively consistent performance. Information for when to seek urgent or emergent care is frequently incomplete and inaccurate, and patients may be unaware of misinformation. Sources are not generally provided. Patients who use AI to guide health care decisions assume potential risks. AI chatbots for health should be subject to further research, refinement, and regulation. We strongly recommend proper medical consultation to prevent potential adverse outcomes.

Osmotic demyelination syndrome: revisiting the diagnostic criteria through two fatal cases.

BACKGROUND: Osmotic Demyelination Syndrome (ODS) encompasses Central Pontine Myelinolysis and Extrapontine Myelinolysis, both of which are serious neurological conditions linked to the overly rapid correction of hyponatremia. Despite growing evidence, the exact etiology of ODS remains incompletely understood. The present paper describes two case studies, aiming to provide a comprehensive overview of the pathological findings and clinical outcomes associated with ODS. CASE PRESENTATION: Case #1. A 74-year-old woman was admitted to the emergency department following a head trauma caused by a loss of consciousness. Initial laboratory tests revealed severe hyponatremia (sodium level of 101 mmol/L) and hypokalemia (potassium level of 2.9 mmol/L). The patient underwent corrective therapy with saline and potassium chloride. Despite the correction of electrolyte imbalances, the patient developed a hyperintense lesion in the median portion of the pons on T2-fluid-attenuated inversion recovery (FLAIR) MRI sequence 14 days post-treatment, consistent with ODS. The patient's condition deteriorated, leading to irreversible coma and status epilepticus, culminating in death 32 days after admission. Case #2. An 81-year-old woman with a medical history of hypothyroidism, hypertension, major depression, and stage 3 chronic kidney disease presented with mild gait disturbances. Subsequent testing revealed severe hyponatremia (sodium level of 100 mmol/L). Following an initial clinical improvement due to sodium correction, the patient's condition worsened, with symptoms progressing to confusion, lethargy, and eventually, ODS. Dermatological manifestations, including blistering lesions and facial edema, appeared as the condition advanced. The patient succumbed to irreversible coma 47 days after admission. CONCLUSION: ODS traditionally carried a poor prognosis, with high mortality rates and diagnoses often made postmortem. However, recent advances in understanding the pathophysiology, along with improvements in diagnostic techniques such as MRI and intensive care treatments, have led to earlier identification, treatment, and recognition of milder forms of the syndrome. Despite these advancements, ODS remains a critical condition with significant risks, particularly following the rapid correction of severe hyponatremia.

Exploring the experiences of healthcare professionals when breaking bad news in major trauma care.

Breaking bad news is a challenging yet essential part of the role of healthcare professionals who care for major trauma patients and their families. This service evaluation investigated healthcare professionals' attitudes and experiences regarding breaking bad news in the context of major trauma. Healthcare professionals were recruited from the South Wales Trauma Network and their views collected via an online survey based on the Breaking Bad News Attitudes Scale. The survey was completed by 149 healthcare professionals and the responses demonstrated a range of experiences of breaking bad news in major trauma care, with challenges such as the environment, building rapport and setting expectations.

Individualized Healthcare Plans: A School Nurse Primer.

According to the 2017 U.S. Census, 74.3 million children younger than 18 years of age live in the United States. Of this group, 14.6 million children and adolescents have special health care needs or a chronic illness. Students who attend school with complex health conditions, including mental and physical diagnoses, require comprehensive planning by a professional school nurse. School nurses should write an individualized healthcare plan (IHP) for these students. An IHP is written by the school nurse in collaboration with the parent/guardians, student, and health care providers. This plan serves as a tool to guide health care for a student throughout the school day and in mandated school-sponsored events.

Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study.

BACKGROUND: This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics' education and training. OBJECTIVE: The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs. METHODS: The study involved 14 Swedish military medics of the Home Guard-National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants' reasoning processes and perceptions and identify possible game elements to inform the VP design. RESULTS: Mapping the military medics' reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, "keep on trying"; agency in interaction with VPs; realistic tactical experience; confidence, "I know that the knowledge I have works"; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making. CONCLUSIONS: Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics' reflections and decision-making.

Addressing abdominal trauma from conflict and warfare in under-resourced regions: A critical narrative review.

Introduction: The prevalence of abdominal injuries in war and conflict zones, particularly in low- and middle-income countries (LMICs), presents a significant healthcare challenge. These injuries, often resulting from explosive devices, firearms, and shrapnel, lead to high morbidity and mortality rates due to delayed diagnoses, inadequate medical infrastructure, and limited access to specialised care. This review aims to summarise the literature on conflict-related abdominal injuries in LMICs, highlighting the impact of such trauma on healthcare systems and patient outcomes, and suggesting strategies for improvement. Methods: A comprehensive narrative review was conducted, focusing on studies from contemporary and historical conflict-ridden nations. Databases such as PubMed, EMBASE, Google Scholar, the Cochrane Library, and Scopus were searched using specific keywords. Inclusion criteria encompassed various study designs and both paediatric and adult populations, with studies providing raw data prioritised. Exclusions included non-English articles, non-peer-reviewed studies, and those not reporting outcomes or involving high-income countries. Results: The review identified significant challenges in managing war-related abdominal trauma in LMICs, including a shortage of healthcare personnel and infrastructure, socio-political barriers, and research gaps. Clinical implications of such injuries include elevated mortality rates, with surgical and nonsurgical management outcomes varying significantly. Positive advancements in diagnostics and surgical techniques have improved survival rates, yet the need for further infrastructural and workforce enhancements remains critical. Conclusion: Abdominal trauma in conflict-affected LMICs necessitates focused efforts to improve healthcare delivery, including targeted funding for infrastructure and equipment, development of training programs for trauma specialists, and increased humanitarian aid. Bridging research gaps and fostering collaborative efforts are essential for advancing the management of abdominal trauma and enhancing patient outcomes in these challenging environments.

Autonomy & advocacy in planning for a medical emergency: Adults with a learning disability and family carers' experiences and perceptions of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process.

Background: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is designed to facilitate meaningful discussions between healthcare professionals, patients, and their family about preferences for treatment in future medical emergencies. People with a learning disability may face particular barriers in completing health care plans and receiving emergency treatment, however little is known about their preferences towards emergency care treatment planning. This study explores the views of people with a learning disability, and family carers about ReSPECT. Methods: A reference group of 5 people with a learning disability contributed to the design of the workshops and evaluation of outputs. Online, arts-based interactive workshops were held with 2 groups of 6 people with a learning disability to explore how they felt about emergency care treatment planning, and to co-produce materials to support ReSPECT conversations. Carers of people with a learning disability participated in focus groups or interviews. Data from workshops, focus groups and interviews were analysed thematically. Results: Themes were; Getting the Process Right, Lack of trust a barrier to ReSPECT planning, and Person-Centred Care. All groups supported the ReSPECT process feeling that ReSPECT plans could support person-centred care, enhancing the autonomy of a person with a learning disability and supporting the advocacy of carers. However, drawing on their previous experiences of the health care system some expressed doubt that their wishes would be carried out. Suggestions were made for improving the ReSPECT process and used to develop resources to support ReSPECT planning. Conclusions: Emergency care planning and ReSPECT are viewed positively by people with a learning disability and family carers. To ensure this works well for people with a learning disability attention should be given to reasonable, personalised adjustments to support their participation in planning conversations. There is a wider challenge of fostering trust in the health care system.

Association Between Intrinsic Capacity and Hospital Admission Among Older Adults in the Emergency Department.

This prospective cohort study assessed the impact of intrinsic capacity on hospital admissions among older adults after an Emergency Department (ED) visit. Assessing 1132 patients according to WHO's Integrated Care for Older People guidelines between March 1 and August 30, 2022, we found that 784 (69.26%) were admitted. The admission group demonstrated significantly lower intrinsic capacity scores (mean ± SD, 2.92 ± 1.29) compared to the discharge group (3.44 ± 1.23; p < .001). Multivariable logistic regression showed that higher intrinsic capacity scores were associated with lower odds of admission (adjusted odds ratio [aOR] = 0.81; 95% CI: 0.71-0.92; p < .001). Notably, patients with malnutrition had significantly higher odds of admission (OR = 3.12; 95% CI: 2.16-4.50; p < .001). These findings underscore the importance of integrating the intrinsic capacity assessment with traditional clinical indicators in the emergency care of older adults.

The patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC): field-testing and validation.

BACKGROUND: Current acute healthcare service metrics are not meaningful for older people living with frailty. Healthcare knowledge, situational security, and physical and psychosocial function are important outcomes typically not collected. The use of patient-reported outcome measures (PROMs) could support these assessments. Existing instruments are not comprehensive as they typically consider function, while older people with frailty also value enablement (self-determination and security in health and healthcare). This study field-tested and validated a PROM for older people with frailty receiving acute care (PROM-OPAC) to measure enablement. METHODS: People aged 65+ with Clinical Frailty Scale 5-8 were recruited within seventy-two hours of an emergency attendance. Iterations of the novel instrument were administered over three stages: (1) preliminary field-testing for reliability (response distribution and internal consistency) and structure (exploratory factor analysis, EFA); (2) intermediate field-testing of an improved instrument for reliability and structure; (3) final draft validation assessing reliability, structure (confirmatory factor analysis, CFA), and construct validity based on a priori hypotheses. Feasibility was appraised throughout using data completeness and response rates and times. RESULTS: 241 people participated. Three items of a preliminary seven-item measure had poor response distribution or loading and were accordingly improved. The intermediate instrument had interpretability issues and three items required further improvement. The final eight-item draft had acceptable reliability (Cronbach's alpha: 0.71), structure (two factors for self-determination and security; RMSEA: 0.065; TLI: 0.917; CFI: 0.944), and construct validity (lower scores from respondents waiting longer and requiring admission). Feasibility was promising (response rate 39%; 98% responses complete; median completion time 11 (IQR: 12) minutes). CONCLUSIONS: Administration of the PROM-OPAC appeared feasible and the instrument had acceptable psychometric properties. Further evaluation is required to assess generalisability.

Prehospital use of spinal precautions by emergency medical services in children and adolescents.

OBJECTIVES: Limited evidence exists to guide the management of children with possible spinal injuries in the prehospital setting. As a first step to address this, we set out to describe the epidemiology and management of children <18 years presenting with possible cervical spinal injuries to EMS in Victoria, Australia. METHODS: Retrospective case record review of all children with concerns of head or neck trauma and/or documented cervical spine collar use presenting to the statewide Ambulance Victoria (AV) EMS service, Victoria, Australia, between 1 July 2019 and 30 June 2020. Demographic, clinical features, mechanism of injury and spinal immobilisation practices were extracted. RESULTS: 2100 children were included; 61% were male and the median age was 13 years (interquartile range: 9-15). Over half of the children were transported to suburban (32.2%) and rural/regional (22.9%) EDs, with 37.5% taken to designated trauma centres. The most common mechanisms of injury were sports/activity, motor vehicle accidents and falls in 35.4%, 27.9% and 26.3%, respectively. Spinal precaution use was recorded in 93.7% of cases; cervical collar use was the most common procedure recorded (87.1%). Younger age groups were less likely to have spinal precautions initiated; 51% of children aged 0-3 years, compared to 96.3% of children aged 12 and older (odds ratio = 23.8; 95% confidence interval = 14.5-37; P < 0.001). CONCLUSIONS: Prehospital spinal precautions were initiated commonly in children, with use increasing with age, and most were transported to suburban, regional and rural hospitals, not trauma centres. These data will inform the integration of emerging paediatric-specific evidence into prehospital guidelines to risk stratify children.

Respiratory viral testing for young febrile infants presenting to emergency care: a planned secondary analysis of the Febrile Infants Diagnostic assessment and Outcome (FIDO) prospective observational cohort study.

OBJECTIVE: To describe the association of respiratory viral test results and the risk of invasive bacterial infection (IBI) for febrile young infants presenting to emergency care. DESIGN: A planned secondary analysis within the Febrile Infants Diagnostic assessment and Outcome (FIDO) study, a prospective multicentre observational cohort study conducted across the UK and Ireland. SETTING: 35 paediatric emergency departments and assessment units across the UK and Ireland between 6 July 2022 and 31 August 2023. PATIENTS: Febrile infants aged 90 days and under presenting to emergency care. MAIN OUTCOME MEASURES: IBI (meningitis or bacteraemia) among febrile infants, undergoing respiratory viral testing for respiratory syncytial virus (RSV), influenza and SARS-CoV-2. RESULTS: 1395 out of 1821 participants underwent respiratory viral testing, of those tested 339 (24.5%) tested positive for at least one of, SARS-CoV-2, RSV or influenza. A total of 45 infants (3.2%) were diagnosed with IBI. Of these, IBI occurred in 40 out of 1056 (3.8%) participants with a negative viral test and 5 out of 339 (1.5%) occurred in participants with a positive viral respiratory test (p=0.034). Infants aged 29 days and older with a positive respiratory viral test had a significantly lower rate of IBI (0.7%) compared with those with a negative test (3.2%) (p=0.015). CONCLUSIONS: Young febrile infants with a positive respiratory viral test for SARS-CoV-2, RSV or influenza are at lower risk of IBI. Infants over 28 days of age with a positive viral test represent the lowest risk cohort. TRIAL REGISTRATION NUMBER: NCT05259683.

Implementing Evidence-Based Pain Management Interventions Into an Emergency Department: Outcomes Guided by Use of the Ottawa Model of Research Use.

AIM: To implement strategies to improve the care of patients with acute pain in the emergency department (ED). DESIGN: Pre-post implementation study using a Type 2 hybrid effectiveness-implementation design. METHODS: Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation. RESULTS: Improvements in time-to-analgesia within 30 min (21%-27%), administration of nurse-initiated analgesia (NIA) (17%-27%) and measurement of pain (65%-75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies. CONCLUSION: Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study. IMPLICATIONS: Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED. IMPACT: This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution in this study.

Assessing Emergency Department Staff Knowledge, Competency, and Implementation of Pre- and Post-Trauma-Informed Care Training.

INTRODUCTION: Trauma-informed care has been posited as a framework for creating ideal and safe environments for patients to participate in treatment. However, there are limited studies that demonstrate the impact of a focused trauma-informed care training on ED staff. We implemented a 4-hour trauma-informed care training in a general emergency department. We aimed to measure changes in knowledge, opinions, self-rated competency, barriers, and recent practices before and after implementing trauma-informed care training. We hypothesized that the training would result in significant self-reported improvement in all domains. METHODS: We performed a pre/post interventional study with the intervention being a trauma-informed care training adapted for ED clinical care staff. A validated, publicly available survey tool (Center for Pediatric Stress Trauma-Informed Care [TIC] Provider Survey) was used to assess knowledge, opinions, competency, and utilization of and perceived barriers to trauma-informed care. Pre- and post-training surveys were collected. Responses were stratified by role. Continuous variables were compared using analysis of variance; categorical variables compared using Pearson's chi-square. RESULTS: Participants demonstrated a high level of perceived knowledge and opinions of trauma-informed care before and after training. We observed significant increases in self-reported competence for all ED staff, some increase in utilization of trauma-informed care in recent practice, and significant decreases in perceived barriers to providing trauma-informed care. DISCUSSION: Trauma-informed care training is an effective means to improving ED staff self-perceived competence and practice of trauma-informed care even among those with high self-perceived knowledge and opinions of trauma-informed care before the training. Future study should explore the patient-level impact of trauma-informed care training, as well as how to continue to reduce barriers to system-wide implementation of trauma-informed care practices.

Evaluating the Economic Impact of the PedAMINES App in Reducing Medication Errors in Pediatric Emergency Care: Cost-Effectiveness Analysis.

BACKGROUND: The administration of drugs in pediatric emergency care is a time-consuming process and is associated with a higher occurrence of medication errors compared with adult care. This is attributed to the intricacies of administration, which involve calculating doses based on the child's weight or age. To mitigate the occurrence of adverse drug events (ADEs), the PedAMINES (Pediatric Accurate Medication in Emergency Situations; Geneva University Hospitals) mobile app has been developed. This app offers a step-by-step guide for preparing and administering pediatric drugs during emergency interventions by automating the dose calculation process. Although previous simulation-based randomized controlled trials conducted in emergency care have demonstrated the efficacy of the PedAMINES app in reducing drug administration errors, there is a lack of evidence regarding its economic implications. OBJECTIVE: This study aims to evaluate the cost-effectiveness of implementing the PedAMINES app for 4 emergency drugs: epinephrine, norepinephrine, dopamine, and midazolam. METHODS: The economic evaluation was conducted by combining hospital data from 2019, previous trial outcomes, information extracted from existing literature, and PedAMINES maintenance costs. The cost per avoided medication error was calculated, along with the number of administrations needed to achieve a positive return on investment. Subsequently, Monte Carlo simulations were used to identify the key parameters contributing to result uncertainty. RESULTS: The study revealed the number of preventable errors per administration for the 4 examined drugs: 0.513 for epinephrine, 0.484 for norepinephrine, 0.500 for dopamine, and 0.671 for midazolam. The cost-effectiveness ratios per ADE prevented were computed as follows: US $4808 for epinephrine, US $9705 for norepinephrine, US $6957 for dopamine, and US $2074 for midazolam. Accounting for the economic impact of ADEs, the analysis estimated that 16 administrations of epinephrine, 17 of norepinephrine and dopamine, and 13 of midazolam would be required to attain a positive return on investment. This corresponds to roughly one-third of the annual administrations at a major university hospital in Switzerland. The primary factors influencing the uncertainty in the estimated cost per ADE include the cost of maintenance of the app, the likelihood of an ADE resulting from an administration error, and the frequency of underdosing in the trial's control group. CONCLUSIONS: A dedicated mobile app presents an economically viable solution to alleviate the health and economic burden of drug administration errors in in-hospital pediatric emergency care. The widespread adoption of this app is advocated to pool costs and extend the benefits on a national scale in Switzerland.

Risk assessment and management strategies in older patients with acute pulmonary embolism.

INTRODUCTION: Managing older patients with acute pulmonary embolism (PE) is challenging due to their underrepresentation in clinical trials, comorbidities and increased complication risk. This study evaluates risk assessment and management outcomes in older PE patients focussing on home and reperfusion treatment. METHODS: A retrospective analysis was conducted on patients aged ≥70 years diagnosed with acute PE at an academic medical centre (2015-2022). RESULTS: 242 patients with a mean age of 77 years were included. All 59 patients with negative Hestia criteria were discharged ≤24h, and in total 81 patients (35%) received home treatment. Among these 14-day mortality and recurrent venous-thromboembolism were 0% and major bleeding occurred in 1.3% (one patient, 95%CI 0.11-6.1). European Society of Cardiology (ESC) risk-classification showed 9 low-risk PE (3.9%), 199 intermediate-risk (87%), and 20 high-risk PE patients (8.8). In 5 of the 20 high-risk patients, hypotension was mainly caused by another condition, i.e. sepsis. Eight high-risk patients received reperfusion therapy. Fourteen-day mortality was 51% in high-risk patients (95%CI 27-71); 5 out of 8 patients receiving reperfusion treatment died within 5 days. Patients with an Acute Presenting Older Patient (APOP) score of ≥45% had higher 14-day mortality (28%; 95%CI 12-46) compared to <45% (3.2%; 95%CI 0.85-8.3; HR 10.2; 95%CI 2.6-39). CONCLUSION: Selecting for home treatment using Hestia was safe for older PE patients in our cohort. Mortality in the high-risk group was high also when receiving reperfusion treatment. The ESC risk-classification and APOP score identified patients at higher mortality risk, suggesting their potential utility in clinical decision-making.

Risk factors of early death in heat stroke and the challenges of emergency care in Hungary - a case series study.

BACKGROUND AND AIM: The increasing frequency of heat waves worldwide is a major challenge for emergency care providers worldwide. The aim of this study was to analyze the clinical features, treatment options, and early outcomes of heat stroke patients presenting to a large academic emergency department (ED) in Hungary and to provide guidance in management for other emergency professionals. METHODS: Patients presenting to the ED between June 1, 2024, and July 31, 2024, with a body temperature above 40 °C were analyzed in a retrospective cohort study. Data collection included demographic, clinical and laboratory parameters. Predictors of mortality were analyzed with Mann-Whitney U test. RESULTS: Eight patients were included in our analysis. Three patients died in the ED (37.5%). Patients who died had significantly lower pH (7.07 vs. 7.4, p = 0.036), higher potassium (7.3 vs. 3.2 mmol/L, p = 0.036), higher calcium (1.19 vs. 0.97 mmol/L, p = 0.036), higher lactate (10.9 vs. 3.5 mmol/L, p = 0.036) and higher PaCO2 (57.2 vs. 28 mmHg, p = 0.036) at admission compared to those who did not die. CONCLUSIONS: The risk of heat stroke due to climate change-induced heat stress and the consequent thermoregulatory disruption may now be significant in temperate climate zones where it was not previously present. Standardization of differential diagnostic and therapeutic procedures could reduce mortality. pH, potassium, lactate and calcium levels may play an important role in predicting the outcome of heat stroke.

Paediatric family activation rapid response (FARR) in acute care: a qualitative study for developing a multilingual application (app) intervention.

BACKGROUND: Delayed recognition of clinical deterioration can result in harm to patients. Parents/carers can often recognise changes in the child's condition before healthcare professionals (HCPs). To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response (FARR) systems are part of family-integrated care. Mechanisms for parents/carers to escalate concerns regarding their child's clinical status remain limited to direct verbal communication, which may impede those with communication/linguistic challenges. AIM: To develop a digital multilingual intervention by which families/carers can escalate their concerns directly to the rapid response team while in acute paediatric care. METHODS: A single-centre qualitative, co-design app development study was conducted. Evidence synthesis from a systematic review of the international literature informed interviews on intervention prototype development using co-design focus groups. Participant recruitment targeted underserved communities for multilingual functionality validity. Data were analysed using qualitative content analysis. RESULTS: Thirty parents/carers (n=16) and HCPs (n=14) participated in the study. Three themes were generated from the data analysis: (1) relational considerations; communication, professional and parental attributes, and collaborative working; (2) technology considerations; app content, usage and outcomes; and (3) individual and environmental considerations; parental and professional elements, and workload. A FARR app prototype was developed based on the data. CONCLUSION: The prototype app provides a platform to develop a coordinated and consistent technological approach to paediatric FARR that acknowledges cultural nuances and preferences, ensuring that parents can communicate in a manner that aligns with their cultural background and communication abilities, thereby enhancing the quality of care delivered.

A systematic review of cost-effectiveness of treating out of hospital cardiac arrest and the implications for resource-limited health systems.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources. OBJECTIVE: To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings. METHODS: The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Six databases (PubMed, EMBASE, Global Health, Cochrane, Global Index Medicus, and Tuft's Cost-Effectiveness Registry) were searched in September 2023. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints. RESULTS: Four hundred and sixty-eight unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in termination of resuscitation protocols, professional prehospital defibrillator use, and CPR training followed by the distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment. CONCLUSION: Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.