Systematic review of factors influencing decisions to limit treatment in the emergency department.

BACKGROUND: Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature. DESIGN: Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis. RESULTS: 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors). CONCLUSIONS: Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise.

BACKGROUND: More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions. METHODS: The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings. RESULTS: The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs. CONCLUSIONS: Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

The use of whole-body computed tomography in major trauma: variations in practice in UK trauma hospitals.

INTRODUCTION: Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. METHODS: We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. RESULTS: Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there was no consistent relation with age. High falls and motor vehicle collisions also increased WBCT usage. Adjusting for casemix, there was a 13-fold intrahospital variation in the use of WBCT between MTCs and a 30-fold variation between TUs/NDHs. The amount of variability between individual hospitals that could not be accounted for by the factors shown to impact on WBCT use was 26% (95% CI 17% to 39%) for MTCs and 17% (95% CI 13% to 21%) for TUs/NDHs. CONCLUSION: There are significant variations in WBCT use between different hospitals in England and Wales, which require further investigation.

Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database.

BACKGROUND: First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. METHODS: Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. RESULTS: There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma, independent of mechanism of injury, age and gender with an adjusted OR of 2.64 (95% CI 2.33 to 3.00) and 2.01 (95% CI 1.80 to 2.25), respectively. Risk-adjusted mortality was the same in patients with first rib fractures and those with other rib fractures (adjusted OR 0.97, 95% CI 0.79 to 1.19). CONCLUSION: First rib fractures are a marker of life-threatening injuries in major trauma, though they do not independently increase mortality. Management of patients with first rib fractures should focus on identification and treatment of associated life-threatening injuries.

Social support in older people: lessons from a developing country.

PURPOSE: The purpose of this study was to determine the level of social support in older people presenting to the Emergency Department of a tertiary hospital in Trinidad. METHODS: This was a prospective observational study, assessing social support in patients ≥65 years presenting to the Emergency Department, using the Sarason Social Support Questionnaire. RESULTS: One hundred sixty-two respondents aged 65 years and older were included. Respondents reported a median Social Support Questionnaire Score (SSQS) of 4.83 and number (SSQN) of 1.67, which did not differ significantly between genders and ethnic groups. Patients who presented via ambulance had a significantly lower SSQS (4.33 vs. 5.16) and SSQN (1.33 vs. 1.92) than those who arrived by their own transport. Respondents reported far greater median family scores (1.33) than non-family scores (0.00). CONCLUSIONS: This study contributes to the understanding of social support for older people in developing countries. The dependence on family support in developing countries may prove challenging in the long term as family structures in these countries change with economic pressures. More extensive research is needed into the phenomenon of social support for older people in developing countries, particularly with the impending expansion of this age group in these countries.

Attitudes and practices regarding resuscitation in emergency departments in Trinidad and Tobago.

BACKGROUND: Ethical issues with regard to resuscitation are increasingly important. Understanding how emergency physicians deal with these problems is essential for the development of policies for resuscitative care. OBJECTIVES: To identify the knowledge, opinions and practices of emergency physicians employed full time in public hospitals in Trinidad and Tobago, with respect to cardiopulmonary resuscitation. To compare the differences in responses between physicians in training and those who were not. In addition, to compare these responses with those expressed in a similar study in the USA in 2007. METHODS: All emergency physicians (120) who fulfilled the eligibility criteria for the study were asked to record anonymous responses to survey questions about ethical issues regarding resuscitation. RESULTS: Of the 98 respondents, most (79.6%) had been practising emergency medicine for ≤5 years and about 38% had had some training in emergency medicine. Most respondents agreed that survival rates for cardiopulmonary resuscitation (CPR) were poor. However, 41.2% of respondents had performed CPR >10 times in the past 3 years despite expected futility. More participants in the US study than in the local study thought that the existence of an advance directive was important in making decisions about CPR and that legal concerns should not, but do, affect CPR decisions in practice. CONCLUSIONS: Local emergency physicians are as affected by legal and ethical CPR issues as are US emergency physicians. Education programmes and policies that deal with these concerns would better assist the emergency physician in dealing with them.

Attitudes of ED staff to the presence of family during cardiopulmonary resuscitation: a Trinidad and Tobago perspective.

INTRODUCTION: Patients' relatives have been allowed in the resuscitation room during active resuscitation in the UK since at least 1994. Several studies have indicated that relatives value the opportunity to observe the care provided, and this has been shown to help the grieving process. However, this enthusiasm has not always been shared by emergency department staff. In Trinidad and Tobago the concept of family presence in the resuscitation room is still a novel one. This study seeks to identify the attitudes of staff towards relatives in the resuscitation room in this setting. METHODS: A cross-sectional survey of attitudes of staff towards family presence in the resuscitation room was undertaken. All full-time doctors and nurses practising in emergency departments in the public sector in Trinidad and Tobago were surveyed, and the responses of doctors and nurses were compared. RESULTS: 214 individuals responded to the questionnaire (108 nurses and 106 doctors). 81.4% of respondents felt that relatives would be traumatised by witnessing resuscitation. 64% felt that staff performance would be inhibited by the presence of a family member during resuscitation. 71.1% believed that allowing a family member to witness resuscitation would prolong the resuscitation. 72% believed that witnessed resuscitation would increase the stress for the staff. CONCLUSION: Strong feelings against the presence of family members in the resuscitation room were expressed by physicians and nurses. Implementation of such a policy will require careful preparation and education of staff as to the benefits of this intervention.

Is the APLS formula used to calculate weight-for-age applicable to a Trinidadian population?

BACKGROUND: In paediatric emergency medicine, estimation of weight in ill children can be performed in a variety of ways. Calculation using the 'APLS' formula (weight = [age + 4] × 2) is one very common method. Studies on its validity in developed countries suggest that it tends to under-estimate the weight of children, potentially leading to errors in drug and fluid administration. The formula is not validated in Trinidad and Tobago, where it is routinely used to calculate weight in paediatric resuscitation. METHODS: Over a six-week period in January 2009, all children one to five years old presenting to the Emergency Department were weighed. Their measured weights were compared to their estimated weights as calculated using the APLS formula, the Luscombe and Owens formula and a "best fit" formula derived (then simplified) from linear regression analysis of the measured weights. RESULTS: The APLS formula underestimated weight in all age groups with a mean difference of -1.4 kg (95% limits of agreement 5.0 to -7.8). The Luscombe and Owens formula was more accurate in predicting weight than the APLS formula, with a mean difference of -0.4 kg (95% limits of agreement 6.9 to -6.1%). Using linear regression analysis, and simplifying the derived equation, the best formula to describe weight and age was (weight = [2.5 x age] + 8). The percentage of children whose actual weight fell within 10% of the calculated weights using any of the three formulae was not significantly different. CONCLUSIONS: The APLS formula slightly underestimates the weights of children in Trinidad, although this is less than in similar studies in developed countries. Both the Luscombe and Owens formula and the formula derived from the results of this study give a better estimate of the measured weight of children in Trinidad. However, the accuracy and precision of all three formulae were not significantly different from each other. It is recommended that the APLS formula should continue to be used to estimate the weight of children in resuscitation situations in Trinidad, as it is well known, easy to calculate and widely taught in this setting.

Cecal volvulus and mucocele of the appendix.

We report the case of a 75-year-old woman who presented the association of a cecal volvulus with an appendiceal mucocele. A laparotomy showed these two findings and a right hemicolectomy with an end-to-end ileo-transverse colonic anastomosis was done. The role of plain radiograph and computerized tomographic imaging in the diagnosis of this entity is discussed To our knowledge, this association has not been reported in the literature.

Assessing the validity of the Triage Risk Screening Tool in a third world setting.

Background Social risk is rarely evaluated in older emergency department (ED) patients, although its identification can reduce re-attendance. Objectives This study assessed the diagnostic accuracy of the Triage Risk Screening Tool (TRST) in the ED of a developing country. Methods The diagnostic accuracy of the TRST to detect elderly adults in need of social service intervention was compared with routine clinical evaluation, using comprehensive evaluation by an experienced social worker as the "gold standard". The inter-rater reliability of the TRST was assessed on a separate cohort of patients prior to the main study. Results The sensitivity of the TRST was 94.7% versus 55.6% for physician assessment. The TRST had good inter-rater reliability (Cohen's kappa = .882), and physicians found it easy to use. Conclusion The TRST provides a rapid means of assessing risk in older ED patients. This study confirmed the validity of this screening tool in a third world setting.

Falling down a flight of stairs: The impact of age and intoxication on injury pattern and severity.

BACKGROUND: Falling down a flight of stairs is a common injury mechanism in major trauma patients, but little research has been undertaken into the impact of age and alcohol intoxication on the injury patterns of these patients. The aim of this study was to compare the impact of age and alcohol intoxication on injury pattern and severity in patients who fell down a flight of stairs. METHODS: This was a retrospective observational study of prospectively collected trauma registry data from a major trauma centre in the United Kingdom comparing older and younger adult patients admitted to the Emergency Department following a fall down a flight of stairs between July 2012 and March 2015. RESULTS: Older patients were more likely to suffer injuries to all body regions and sustained more severe injuries to the spine; they were also more likely to suffer polytrauma (23.6% versus 10.6%; p < 0.001). Intoxicated patients were more likely to suffer injuries to the head and neck (42.9% versus 30.5%; p = 0.006) and were significantly younger than sober patients (53 versus 69 years; p < 0.001). CONCLUSION: Older patients who fall down a flight of stairs are significantly different from their younger counterparts, with a different injury pattern and a greater likelihood of polytrauma. In addition, alcohol intoxication also affects injury pattern in people who have fallen down a flight of stairs, increasing the risk of traumatic brain injury. Both age and intoxication should be considered when managing these patients.

The simulated Trauma Patient Teaching Module--does it improve student performance?

BACKGROUND: Student feedback from the old TEAM (Trauma Evaluation and Management) program prompted introduction of simulated trauma patient models in the new program. Performance after the new and old programs was compared to assess the impact of the simulated patient models. METHODS: Final year medical students randomly assigned to control and experimental groups completed a 20-item trauma multiple choice questionnaire examination (MCQE). The experimental groups attended the old or new TEAM program before completing a second MCQE and the control groups completed the same post-test without the TEAM programs. We used paired t tests for within and unpaired t tests for between group comparisons of the control and experimental groups' performances on the MCQ pre- and post-tests. On a 1 to 5 scale, students graded if objectives were met; trauma knowledge improved; trauma skills improved; overall satisfaction; and if TEAM should be mandatory. RESULTS: Post-test scores increased significantly after both the old and new programs but the increase was statistically significantly greater after the new program. In the old TEAM, 51.6% rated improvement in trauma skills at 4 or greater compared with 97.3% in the new program. A large percentage of students in the old program requested more hands-on teaching. Of students, 85% scored honors pass mark after completion of the new TEAM format, and no honors pass marks were achieved after completion of the old TEAM format. CONCLUSION: Simulated trauma patient models were rated highly and improved both trauma skills and knowledge. Wider application of these teaching models is suggested.

End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis.

With population aging, "do not resuscitate" (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents "ageism." We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that "do not attempt resuscitation" orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of "do not resuscitate" orders, but more research is needed to determine whether this represents "ageism."

Polypharmacy and potential drug-drug interactions in emergency department patients in the Caribbean.

Background Potential Drug-Drug Interactions (DDI) account for many emergency department visits. Polypharmacy, as well as herbal, over-the-counter (OTC) and combination medication may compound this, but these problems are not well researched in low-and-middle-income countries. Objective To compare the incidence of drug-drug interactions and polypharmacy in older and younger patients attending the Emergency Department (ED). Setting The adult ED of a tertiary teaching hospital in Trinidad. Methods A 4 month cross sectional study was conducted, comparing potential DDI in older and younger patients discharged from the ED, as defined using Micromedex 2.0. Main outcome measure The incidence and severity of DDI and polypharmacy (defined as the use of ≥5 drugs simultaneously) in older and younger patients attending the ED. Results 649 patients were included; 275 (42.3%) were ≥65 years and 381 (58.7%) were female. There were 814 DDIs, of which 6 (.7%) were contraindications and 148 (18.2%) were severe. Polypharmacy was identified in 244 (37.6%) patients. Older patients were more likely to have potential DDI (67.5 vs 48.9%) and polypharmacy (56 vs 24.1%). Herbal products, OTC and combination drugs were present in 8, 36.7 and 22.2% of patients, respectively. On multivariate analysis, polypharmacy and the presence of hypertension and ischaemic heart disease were associated with an increased risk of potential DDI. Conclusion Polypharmacy and potential drug-drug interactions are common in ED patients in the Caribbean. Older patients are particularly at risk, especially as they are more likely to be on multiple medications. The association between herbal medication and polypharmacy needs further investigation. This study indicates the need for a more robust system of drug reconciliation in the Caribbean.

Factors affecting mortality in older trauma patients-A systematic review and meta-analysis.

INTRODUCTION: Major trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury. MATERIALS AND METHODS: A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis. Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review. RESULTS: 3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality. The 'oldest old', aged 75 and older, had higher mortality rates than younger patients, aged 65-74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37-1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05-1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26-6.60). CONCLUSIONS: Multiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.

Trauma in the elderly in Trinidad and Tobago: a cross-sectional study.

Little is known about trauma in the elderly in the developing world. This study compared injuries in older patients with those in younger adults in a Third World setting. This was a prospective observational study of trauma admissions to a tertiary hospital in Trinidad, comparing injury characteristics and patient outcomes in older versus younger adults. Falls were the most common mechanism of injury in the elderly, accounting for 71% of injuries. Older patients who fell sustained fractures more often and were most likely to injure the limbs and head. Elderly patients were more likely to be admitted to hospital. Trauma in the elderly in Trinidad is similar to that in the developed world. Public health measures in developing countries should be aimed at preventing falls in older persons. The burden of trauma in the elderly is likely to increase in developing countries as the population ages.

Towards evidence based emergency medicine: best BETs from Manchester Royal Infirmary. Antibiotics in patients with isolated chest trauma requiring chest drains.

A short cut review was carried out to establish whether the administration of antibiotics reduces the incidence of intrathoracic infection in patients who have had a chest drain inserted after trauma. Altogether 321 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.