Results of Reduction of Dislocated Prosthetic Hips in the Emergency Department.

BACKGROUND: Dislocation of total hip arthroplasty (dTHA) is a commonly encountered complication in the emergency department (ED). Several studies have been conducted that describe the overall success rate after reduction in the ED, however, all were small in sample size. OBJECTIVES: The aim of the study was to assess the success rate of reduction of dTHA by emergency physicians in the ED under procedural sedation (PSA). METHODS: Patients who presented to the ED with a dislocated prosthetic hip were eligible for inclusion. We performed a retrospective cohort study assessing success rate. Secondary parameters included time to reduction, discharge rate from the ED, and complication rate. RESULTS: There were 305 patients analyzed. Of these, 31 were excluded due to hemi-arthroplasty and 25 because they went primarily for reduction in the operating room. In total, 249 patients were included. Of 249 attempted reductions in the ED, 230 (92%, 95% confidence interval [CI] 89-96%) were successful. Seventy-one cases (28.5%, 95% CI 22.9-34.2%) were discharged from the ED after successful reduction. Six cases (2.4%, 95% CI 0.2-2.6%) experienced complications related to PSA and three cases (1.2%, 95% CI 0.5-4.3%) experienced complications related to reduction. CONCLUSION: Reduction of a dTHA can be performed safely in the ED under PSA by emergency physicians with a high rate of success.

Holding the frontline: a cross-sectional survey of emergency department staff well-being and psychological distress in the course of the COVID-19 outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak has been associated with stress and challenges for healthcare professionals, especially for those working in the front-line of treating COVID-19 patients. This study aimed to: 1) assess changes in well-being and perceived stress symptoms of Dutch emergency department (ED) staff in the course of the first COVID-19 wave, and 2) assess and explore stressors experienced by ED staff since the COVID-19 outbreak. METHODS: We conducted a cross-sectional study. An online questionnaire was administered during June-July 2020 to physicians, nurses and non-clinical staff of four EDs in the Netherlands. Well-being and stress symptoms (i.e., cognitive, emotional and physical) were scored for the periods pre, during and after the first COVID-19 wave using the World Health Organization Well-Being Index (WHO-5) and a 10-point Likert scale. Stressors were assessed and explored by rating experiences with specific situations (i.e., frequency and intensity of distress) and in free-text narratives. Quantitative data were analyzed with descriptive statistics and generalized estimating equations (GEE). Narratives were analyzed thematically. RESULTS: In total, 192 questionnaires were returned (39% response). Compared to pre-COVID-19, the mean WHO-5 index score (range: 0-100) decreased significantly with 14.1 points (p < 0.001) during the peak of the first wave and 3.7 points (< 0.001) after the first wave. Mean self-perceived stress symptom levels almost doubled during the peak of the first wave (≤0.005). Half of the respondents reported experiencing more moral distress in the ED since the COVID-19 outbreak. High levels of distress were primarily found in situations where the staff was unable to provide or facilitate necessary emotional support to a patient or family. Analysis of 51 free-texts revealed witnessing suffering, high work pressure, fear of contamination, inability to provide comfort and support, rapidly changing protocols regarding COVID-19 care and personal protection, and shortage of protection equipment as important stressors. CONCLUSIONS: The first COVID-19 wave took its toll on ED staff. Actions to limit drop-out and illness among staff resulting from psychological distress are vital to secure acute care for (non-)COVID-19 patients during future infection waves.

[Opioid use and misuse among patients at the emergency department]. / Opioïdgebruik en -misbruik onder patiënten op de SEH.

OBJECTIVE: To determine the prevalence of use and misuse of prescription opioids among patients at Dutch emergency departments (EDs). DESIGN: Cross-sectional multicenter study. METHOD: This study was performed at three EDs in the Nijmegen-Arnhem region. ED-patients of 18 years and older were screened for current opioid use. The Current Opioid Misuse Measure (COMM) questionnaire was used to assess opioid misuse. The presence of opioid use disorder was determined using DSM-5 based interviews. RESULTS: A total of 997 patients was screened for opioid use. The prevalence of opioid use was 15.0% (95%CI 12.9 -17.4). 22.6% (95%CI 14.6-32.4) scored positive for opioid misuse, 9.8% (95%CI 4.5-17.8) fulfilled DSM-5 criteria for opioid use disorder. CONCLUSION: Opioid use and misuse are relatively common among patients in Dutch EDs.

The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands.

RATIONALE: Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking. AIMS AND OBJECTIVES: This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription. METHODS: In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups. RESULTS: A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD. CONCLUSION: This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.

New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation.

BACKGROUND: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. AIM: To develop and validate a sepsis prediction model for adult patients in primary care. DESIGN AND SETTING: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. METHOD: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. RESULTS: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation. CONCLUSION: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

Trend analysis of emergency department malpractice claims in the Netherlands: a retrospective cohort analysis.

BACKGROUND: Over the past two decades, several quality improvement projects have been implemented in emergency departments (EDs) in the Netherlands, one of these being the training and deployment of emergency physicians. In this study we aim to perform a trend analysis of ED quality of care in Dutch hospitals, as measured by the incidence of medical malpractice claims. PATIENTS AND METHODS: We performed a multicentre retrospective cohort study of malpractice claims in five Dutch EDs over the period 1998-2014. Incidence risk ratios were calculated to demonstrate any relation of specific quality improvement initiatives with the primary outcome, defined as the number of claims per 10 000 ED visits per year. RESULTS: During the study period, the cumulative number of ED visits increased significantly from 99 145 in 1998 to 162 490 in 2014 (P < 0.01). In total, 228 of 2 348 417 ED visits (0.97 per 10 000) resulted in a malpractice claim. At the same time, the yearly number of ED claims filed decreased with 0.07 (0.03-0.10) per 10 000 each year. The claim rate was higher in the period before emergency physicians were employed in the ED [1.18 (0.98-1.41) claims per 10 000 visits] compared with the period after they were employed [0.81 (0.67-0.97), incidence risk ratio 0.69 (0.53-0.89), P < 0.01]. CONCLUSION: Even though the number of ED visits increased significantly over the past two decades, the number of malpractice claims filed after an ED visit decreased. Various quality improvement initiatives, including the training and employment of emergency physicians, may have contributed to the observed decrease in claims.