Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary.

AIM: Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group. RESULTS: The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice. CONCLUSIONS: The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

The association between inflammation, arterial stiffness, oxidized LDL and cardiovascular disease in Finnish men with metabolic syndrome - a 15-year follow-up study.

BACKGROUND: All-cause mortality and cardiovascular disease are increased in subjects with metabolic syndrome (MetS). Risk scores are used to predict individual risk of heart disease. We performed a long-term follow-up study to investigate whether risk scores and cardiovascular risk factors such as arterial stiffness, high-sensitive C-reactive protein (hs-CRP) and oxidized LDL (OxLDL) can be used to predict cardiovascular events in Finnish men with MetS. METHODS: After baseline measurements we followed 105 Finnish men aged 30 to 65 years with MetS for a mean period of 16.4 years. The primary outcome of the study was a composite of myocardial infarction, stroke, symptomatic vascular disease diagnosed with invasive angiography, coronary or peripheral revascularization, amputation due to peripheral vascular disease, cardiovascular death and non-cardiovascular death. The endpoints were retrieved from electronic medical records. RESULTS: The number of acute myocardial infarctions and strokes during the first 10 years was lower than estimated by FINRISK score but SCORE predicted cardiovascular death correctly. During the whole follow-up period, 27 of 105 participants (25.8%) had 30 endpoint events. The incidence of the primary composite outcome was significantly lower in subjects with hs-CRP < 1.0 mg/L than in subjects with hs-CRP ≥ 1.0 mg/L (6 of 41 subjects [14.6%] vs. 21 of 64 subjects [32.8%]; p = 0.036). The incidence of the primary composite outcome was higher among subjects with large artery elasticity classified as borderline compared to subjects with normal large artery elasticity (5 of 10 subjects [50%] vs. 22 of 93 subjects [24%]; p = 0.05). There was no difference in the incidence of primary composite outcome in groups with different degrees of small artery elasticity or different level of oxLDL. CONCLUSIONS: Men with MetS who had hs-CRP ≥ 1.0 mg/L had higher risk for CVD and all-cause mortality than those with hs-CRP of < 1.0 mg/L. This also applies to subjects with borderline decreased large artery elasticity. The amount of OxLDL had no predictive value on the incidence of CVD and all-cause mortality. Men with MetS participating in the Hämeenlinna Metabolic Syndrome Research Program without lifestyle or drug intervention had better outcome for myocardial infarction or stroke than estimated by the FINRISK score. TRIAL REGISTRATION: ClinicalTrials.gov NCT01119404 retrospectively registered 07/05/2010.

Current postgraduate training in emergency medicine in the Nordic countries.

BACKGROUND: Emergency Medicine (EM) is an independent specialty in all five Nordic countries. This study aims to evaluate the structure of post-graduate EM training in the area. METHODS: A leading hospital or hospitals in EM training in each country were identified. An e-survey was sent to each hospital to gather data on patient volume and physician staffing, curriculum, trainee supervision, and monitoring of progression in training. RESULTS: Data were collected from one center in Iceland and Norway, two in Finland and Sweden, and four centers in Denmark. The data from each country in Denmark, Finland, and Sweden, were pooled to represent that country. The percentage of consultants with EM specialist recognition ranged from 49-100% of all consultants working in the participating departments. The number of patients seen annually per each full time EM consultant was almost three times higher in Finland than in Sweden. In Iceland, Denmark, and Sweden a consultant was present 24/7 in the ED but not in all centers in the other countries. The level of trainee autonomy in clinical practice varied between countries. Requirements for completing standardized courses, completing final exams, scientific and quality improvement projects, and evaluation of trainee progression, varied between the countries. CONCLUSIONS: All Nordic countries have established EM training programs. Despite cultural similarities, there are significant differences in how the EM training is structured between the countries. Writing and implementing a standardized training curriculum and assessment system for EM training in the Nordic countries should be considered.

Self-reported skills and self-confidence in point-of-care ultrasound: a cross-sectional nationwide survey amongst Finnish emergency physicians.

BACKGROUND: The use of point-of-care ultrasound (POCUS) is increasing. Numerous investigators have evaluated the learning curves in POCUS, but there are no published studies on how emergency physicians perceive their own competence level with this skill. METHODS: A nationwide survey amongst Finnish emergency physicians was conducted. The respondents reported their use of POCUS and how it has affected their clinical decision-making. The number of POCUS examinations performed was compared to the self-assessed skill level with different applications. Cut-off values were determined for the number of examinations required to acquire a good self-assessed skill level in each POCUS application. The correlation between self-confidence and the self-estimated skill level was analyzed. Several different statistical methods were used, such as Student's t-test, Pearson's correlation test, Loess method and ROC curve analysis. RESULTS: A total of 134 out of 253 Finnish emergency medicine specialists and residents (52%) responded to the survey. The most commonly used POCUS applications were POCUS-assisted procedures, pleural effusion and pneumothorax, inferior vena cava and lower extremity deep venous thrombosis. The initial rate of perceived skill acquisition was very steep with the curve flattening with greater skill and more experience. The number of examinations performed to reach a self-assessed good competence varied from seven to 75 with different applications. The lowest cut-off point for self-assessed good competence was obtained for rapid ultrasound for the shock and hypotension-protocol and the highest for focused cardiac examinations. There was an excellent correlation between self-confidence and the self-assessed skill level. CONCLUSIONS: The Finnish emergency practitioners' self-assessed development of POCUS skills parallels the previously published learning curves of POCUS. The correlation of self-confidence and the self-assessed skill level was found to be excellent. These findings add information on the development of perceived POCUS skills amongst emergency physicians and could complement a formal performance assessment.

Early Warning Software for Emergency Department Crowding.

Emergency department (ED) crowding is a well-recognized threat to patient safety and it has been repeatedly associated with increased mortality. Accurate forecasts of future service demand could lead to better resource management and has the potential to improve treatment outcomes. This logic has motivated an increasing number of research articles but there has been little to no effort to move these findings from theory to practice. In this article, we present first results of a prospective crowding early warning software, that was integrated to hospital databases to create real-time predictions every hour over the course of 5 months in a Nordic combined ED using Holt-Winters' seasonal methods. We show that the software could predict next hour crowding with an AUC of 0.94 (95% CI: 0.91-0.97) and 24 hour crowding with an AUC of 0.79 (95% CI: 0.74-0.84) using simple statistical models. Moreover, we suggest that afternoon crowding can be predicted at 1 p.m. with an AUC of 0.84 (95% CI: 0.74-0.91).

Forecasting daily emergency department arrivals using high-dimensional multivariate data: a feature selection approach.

BACKGROUND AND OBJECTIVE: Emergency Department (ED) overcrowding is a chronic international issue that is associated with adverse treatment outcomes. Accurate forecasts of future service demand would enable intelligent resource allocation that could alleviate the problem. There has been continued academic interest in ED forecasting but the number of used explanatory variables has been low, limited mainly to calendar and weather variables. In this study we investigate whether predictive accuracy of next day arrivals could be enhanced using high number of potentially relevant explanatory variables and document two feature selection processes that aim to identify which subset of variables is associated with number of next day arrivals. Performance of such predictions over longer horizons is also shown. METHODS: We extracted numbers of total daily arrivals from Tampere University Hospital ED between the time period of June 1, 2015 and June 19, 2019. 158 potential explanatory variables were collected from multiple data sources consisting not only of weather and calendar variables but also an extensive list of local public events, numbers of website visits to two hospital domains, numbers of available hospital beds in 33 local hospitals or health centres and Google trends searches for the ED. We used two feature selection processes: Simulated Annealing (SA) and Floating Search (FS) with Recursive Least Squares (RLS) and Least Mean Squares (LMS). Performance of these approaches was compared against autoregressive integrated moving average (ARIMA), regression with ARIMA errors (ARIMAX) and Random Forest (RF). Mean Absolute Percentage Error (MAPE) was used as the main error metric. RESULTS: Calendar variables, load of secondary care facilities and local public events were dominant in the identified predictive features. RLS-SA and RLS-FA provided slightly better accuracy compared ARIMA. ARIMAX was the most accurate model but the difference between RLS-SA and RLS-FA was not statistically significant. CONCLUSIONS: Our study provides new insight into potential underlying factors associated with number of next day presentations. It also suggests that predictive accuracy of next day arrivals can be increased using high-dimensional feature selection approach when compared to both univariate and nonfiltered high-dimensional approach. Performance over multiple horizons was similar with a gradual decline for longer horizons. However, outperforming ARIMAX remains a challenge when working with daily data. Future work should focus on enhancing the feature selection mechanism, investigating its applicability to other domains and in identifying other potentially relevant explanatory variables.

The emergency department arrival mode and its relations to ED management and 30-day mortality in acute heart failure: an ancillary analysis from the EURODEM study.

BACKGROUND: Acute heart failure patients are often encountered in emergency departments (ED) from 11% to 57% using emergency medical services (EMS). Our aim was to evaluate the association of EMS use with acute heart failure patients' ED management and short-term outcomes. METHODS: This was a sub-analysis of a European EURODEM study. Data on patients presenting with dyspnoea were collected prospectively from European EDs. Patients with ED diagnosis of acute heart failure were categorized into two groups: those using EMS and those self-presenting (non- EMS). The independent association between EMS use and 30-day mortality was evaluated with logistic regression. RESULTS: Of the 500 acute heart failure patients, with information about the arrival mode to the ED, 309 (61.8%) arrived by EMS. These patients were older (median age 80 vs. 75 years, p < 0.001), more often female (56.4% vs. 42.1%, p = 0.002) and had more dementia (18.7% vs. 7.2%, p < 0.001). On admission, EMS patients had more often confusion (14.2% vs. 2.1%, p < 0.001) and higher respiratory rate (24/min vs. 21/min, p = 0.014; respiratory rate > 30/min in 17.1% patients vs. 7.5%, p = 0.005). The only difference in ED management appeared in the use of ventilatory support: 78.3% of EMS patients vs. 67.5% of non- EMS patients received supplementary oxygen (p = 0.007), and non-invasive ventilation was administered to 12.5% of EMS patients vs. 4.2% non- EMS patients (p = 0.002). EMS patients were more often hospitalized (82.4% vs. 65.9%, p < 0.001), had higher in-hospital mortality (8.7% vs. 3.1%, p = 0.014) and 30-day mortality (14.3% vs. 4.9%, p < 0.001). The use of EMS was an independent predictor of 30-day mortality (OR = 2.54, 95% CI 1.11-5.81, p = 0.027). CONCLUSION: Most acute heart failure patients arrive at ED by EMS. These patients suffer from more severe respiratory distress and receive more often ventilatory support. EMS use is an independent predictor of 30-day mortality.

NYU-EDA in modelling the effect of COVID-19 on patient volumes in a Finnish emergency department.

BACKGROUND: Emergency departments (EDs) worldwide have been in the epicentre of the novel coronavirus disease (COVID-19). However, the impact of the pandemic and national emergency measures on the number of non-COVID-19 presentations and the assessed acuity of those presentations remain uncertain. METHODS: We acquired a retrospective cohort containing all ED visits in a Finnish secondary care hospital during years 2018, 2019 and 2020. We compared the number of presentations in 2020 during the national state of emergency, i.e. from March 16 to June 11, with numbers from 2018 and 2019. Presentations were stratified using localized New York University Emergency Department Algorithm (NYU-EDA) to evaluate changes in presentations with different acuity levels. RESULTS: A total of 27,526 presentations were observed. Compared to previous two years, total daily presentations were reduced by 23% (from 113 to 87, p < .001). In NYU-EDA classes, Non-Emergent visits were reduced the most by 42% (from 18 to 10, p < .001). Emergent presentations were reduced by 19 to 28% depending on the subgroup (p < .001). Number of injuries were reduced by 25% (from 27 to 20, p < .001). The NYU-EDA distribution changed statistically significantly with 4% point reduction in Non-Emergent visits (from 16 to 12%, p < .001) and 0.9% point increase in Alcohol-related visits (from 1.6 to 2.5%, p < .001). CONCLUSIONS: We observed a significant reduction in total ED visits in the course of national state of emergency. Presentations were reduced in most of the NYU-EDA groups irrespective of the assessed acuity. A compensatory increase in presentations was not observed in the course of the 3 month lockdown. This implies either reduction in overall morbidity caused by decreased societal activity or widespread unwillingness to seek required medical advice.

Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study.

BACKGROUND: Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate. METHODS: This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease. RESULTS: Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED. CONCLUSIONS: Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.

Pericolic or paracolic? The right word in the right place for acute diverticulitis.

KEY POINT: • The term "pericolic" is wrongly used to describe an abscess adjacent to the colon in patients with acute diverticulitis. We explain why the proper term is the word "paracolic."

Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians.

STUDY OBJECTIVE: Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available. METHODS: This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization. RESULTS: A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization. CONCLUSION: Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.

Subclinical inflammation associated with prolonged TIMP-1 upregulation and arterial stiffness after gestational diabetes mellitus: a hospital-based cohort study.

BACKGROUND: Gestational diabetes mellitus (GDM) has significant implications for the future health of the mother. Some clinical studies have suggested subclinical inflammation and vascular dysfunction after GDM. We aimed to study whether concentrations of high-sensitivity C-reactive protein (hsCRP), tissue inhibitor of metalloproteinase-1 (TIMP-1), matrix metalloproteinase-8 (MMP-8) and -9, as well as values of arterial stiffness differ between women with and without a history of GDM a few years after delivery. We also investigated possible effects of obesity on the results. METHODS: We studied two cohorts-120 women with a history of GDM and 120 controls-on average 3.7 years after delivery. Serum concentrations of hsCRP were determined by immunonephelometric and immunoturbidimetric methods, MMP-8 by immunofluorometric assay, and MMP-9 and TIMP-1 by enzyme-linked immunosorbent assays. Pulse wave velocity (PWV) was determined using the foot-to-foot velocity method from carotid and femoral waveforms by using a SphygmoCor device. Arterial compliance was measured non-invasively by an HDI/PulseWave™CR-2000 arterial tonometer. All 240 women were also included in subgroup analyses to study the effect of obesity on the results. Multiple linear regression analyses were performed with adjustment for confounding factors. RESULTS: PWV after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 6.44 ± 0.83 (SD) vs. 6.17 ± 0.74 m/s (p = 0.009). Previous GDM was also one of the significant determinants of PWV in multiple linear regression analyses. On the other hand, compliance indices of both large (p = 0.092) and small (p = 0.681) arteries did not differ between the study cohorts. Serum TIMP-1 levels were significantly increased after previous GDM (p = 0.020). However, no differences were found in the serum levels of MMP-8, MMP-9 or hsCRP. In subgroup analyses, there were significantly higher concentrations of hsCRP (p = 0.015) and higher PWV (p < 0.001) among obese women compared with non-obese ones. CONCLUSIONS: PWV values were significantly higher after GDM compared with normoglycemic pregnancies and were associated with prolonged TIMP-1 upregulation. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM.

Oxidized LDL, insulin resistance and central blood pressure after gestational diabetes mellitus.

INTRODUCTION: Gestational diabetes mellitus (GDM) is an indicator of future cardiovascular disease. We investigated whether sensitive biomarkers of increased cardiovascular risk differ between women with and without a history of GDM few years after pregnancy, and whether obesity affects the results. MATERIAL AND METHODS: We studied two cohorts - 120 women with a history of GDM and 120 controls, on average 3.7 years after delivery. Circulating concentrations of oxidized low-density lipoprotein (oxLDL) were determined by ELISA. The homeostasis model assessment of insulin resistance (HOMA-IR) index was used to estimate insulin resistance. Central blood pressure (cBP) was measured noninvasively from a radial artery pulse wave. The primary outcomes were possible differences in oxLDL, HOMA-IR or cBP between the groups. Secondly, we investigated the influence of obesity on the results, also using adjusted multiple linear regression analyses. RESULTS: OxLDL concentrations or cBP did not differ between the two cohorts, but HOMA-IR was significantly higher in women with previous GDM than in controls, 1.3 ± 0.9 (SD) and 1.1 ± 0.9, respectively (p = 0.022). In subgroup analyses, HOMA-IR (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) cBP were significantly higher in obese subgroups compared with non-obese ones. Body mass index was an important determinant of HOMA-IR and cBP in multiple linear regression analyses. CONCLUSIONS: Over 3 years after delivery, women with GDM were still more insulin-resistant than controls. Obesity turned out to be a more important determinant of insulin resistance and cBP compared with GDM.

[Ultrasound in the hands of emergency physicians]. / Kaikukuvaus akuuttilääkärin työkaluna.

Emergency ultrasound (US) offers additive value in the diagnosis and treatment of emergency and/or critically ill patients. Emergency Medicine (EM) became a new specialty in Finland in the beginning of 2013. Since then, the training of emergency US has dramatically increased. We discuss the current situation of emergency US as a part of specialist training of EM in Finland and compare it with that in the United States and Canada. Practical indications, limitations and future prospects of emergency US are also presented.

Specialist training of Emergency Medicine in Finland.

Emergency Medicine with a six-year specialist training became a main specialty in Finland in the beginning of 2013. Specialist training has developed very quickly over just a few years. In the frontline clinics, the clinical results have already reached high international quality. When developing a new specialty, not only active research and high-quality training but also good co-operation with other specialties are of utmost importance.

Associations of metabolic syndrome and diabetes mellitus with 16-year survival after CABG.

BACKGROUND: The associations of metabolic syndrome (MetS) or diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) have not been extensively evaluated. The aim of the present study was to assess the impact of MetS and DM on the 16-year survival after CABG. METHODS: Diabetic and metabolic status together with relevant cardiovascular data was established in 910 CABG patients operated in 1993-94. They were divided in three groups as follows: neither DM nor MetS (375 patients), MetS alone (279 patients) and DM with or without MetS (256 patients). The 16-year follow-up of patient survival was carried out using national health databases. The relative survival rates were analyzed using the Life Table method comparing the observed survival rates of three patient groups to the rates based on age-, sex- and time-specific life tables for the whole population in Finland. To study the independent significance of MetS and DM for clinical outcome, multivariate analysis was made using an optimizing stepwise procedure based on the Bayesian approach. RESULTS: Bayesian multivariate analysis revealed together six variables to predict clinical outcome (2 months to 16 years) in relation to the national background population, i.e. age, diabetes, left ventricular ejection fraction, BMI, perfusion time during the CABG and peripheral arterial disease. Our principal finding was that after postoperative period the 16-year prognosis of patients with neither DM nor MetS was better than that of the age-, sex-and time-matched background population (relative survival against background population 1.037, p < 0.0001). The overall survival of MetS patients resembled that of the matched background population (relative survival 0.998, NS). DM was associated with significantly increased mortality (relative survival 0.86, p < 0.0001). Additionally, mortality was even higher in patients receiving insulin treatment than in those without. Excess death rate of DM patients was predominantly caused by cardiovascular causes. CONCLUSION: In this long-term follow-up study patient groups without diabetes had at least equal 16 years' survival after CABG than their matched background populations. Survival of DM patients started to deteriorate already few years after the operation.

[Specialist training of emergency medicine in a secondary care hospital]. / Akuuttilääketieteen erikoislääkärikoulutus keskussairaalassa.

Emergency Medicine (EM) was established as a speciality in Finland in the beginning of 2013. The training period of six years conforms to the principles of the European Curriculum for EM. We present here the first-year training in Kanta-Häme Central Hospital, located in Southern Finland. Training is not only based on "learning by doing". Lunchtime lectures covering a wide variety of topics in EM are an essential part of our weekly education day. This day also offers to the residents small group sessions with abstracts, case reports, focused lectures and ultrasound training. A successful training program of EM is achievable by good collaboration with other specialities.

A four-way patient search method for the retrospective identification of poisoning patients.

When studying emergency department (ED) visits, electronic health record systems of hospitals provide a good basis for retrospective studies. However, many intoxication patients presenting to the ED, may not be identified retrospectively if only a single search method is applied. In this study, a new four-way combined patient search method was used to retrospectively identify intoxication patients presenting to the ED. The search included reason for admission to the ED, laboratory results related to intoxication diagnostics, ICD-10 codes, and a novel free word search (FWS) of patient records. After the automated search, the researcher read the medical records of potential substance abuse patients to form comprehensive profiles and remove irrelevant cases. The addition of a free word search identified 36% more substance abuse patients than the combination of the other three methods mentioned above. Patients identified by the FWS search alone were generally admitted to the ED for trauma or mental health problems and were often found to be heavily under the influence of alcohol and/or drugs. The main intoxicants were ethanol and benzodiazepines. The free word search was highly complementary to traditional patient search methods, highlighting the importance of the combined patient search method in retrospective data collection.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study.

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient's arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07-1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04-1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

Clinical Characteristics and Management of Patients with a Suspected COVID-19 Infection in Emergency Departments: A European Retrospective Multicenter Study.

Background: Our aim is to describe and compare the profile and outcome of patients attending the ED with a confirmed COVID-19 infection with patients with a suspected COVID-19 infection. Methods: We conducted a multicentric retrospective study including adults who were seen in 21 European emergency departments (ED) with suspected COVID-19 between 9 March and 8 April 2020. Patients with either a clinical suspicion of COVID-19 or confirmed COVID-19, detected using either a RT-PCR or a chest CT scan, formed the C+ group. Patients with non-confirmed COVID-19 (C− group) were defined as patients with a clinical presentation in the ED suggestive of COVID-19, but if tests were performed, they showed a negative RT-PCR and/or a negative chest CT scan. Results: A total of 7432 patients were included in the analysis: 1764 (23.7%) in the C+ group and 5668 (76.3%) in the C− group. The population was older (63.8 y.o. ±17.5 vs. 51.8 y.o. +/− 21.1, p < 0.01), with more males (54.6% vs. 46.1%, p < 0.01) in the C+ group. Patients in the C+ group had more chronic diseases. Half of the patients (n = 998, 56.6%) in the C+ group needed oxygen, compared to only 15% in the C− group (n = 877). Two-thirds of patients from the C+ group were hospitalized in ward (n = 1128, 63.9%), whereas two-thirds of patients in the C− group were discharged after their ED visit (n = 3883, 68.5%). Conclusion: Our study was the first in Europe to examine the emergency department's perspective on the management of patients with a suspected COVID-19 infection. We showed an overall more critical clinical situation group of patients with a confirmed COVID-19 infection.