Impediments to and impact of checklists on performance of emergency interventions in primary care: an in situ simulation-based randomized controlled trial.

OBJECTIVE: Medical crises occur rather seldom in the primary care setting, but when they do, initial management impacts on morbidity and mortality. Factors that impede the performance of emergency interventions in primary care have not been studied through in-situ simulation. Checklists reportedly improve crisis management. DESIGN: This randomized controlled trial evaluated emergency intervention performance during two scenarios (hypoglycemia-coma and anaphylaxis-cardiac arrest) simulated at primary care centers, and whether checklist access improved performance. SETTING: Twenty-two primary care centers in Southern Sweden participated in the study. SUBJECTS: A total of 347 personnel performed 100 simulations, 45 with and 55 without checklist access. MAIN OUTCOME MEASURES: Time and impediments to performance of five emergency interventions in each scenario. RESULTS: On 28 of the 37 occasions when the adrenalin auto-injector was employed, the administration technique was incorrect. In 9 of 49 scenarios, teams had trouble locating the 30% glucose solution. Median time to supplemental oxygen administration during the first scenario was 186 s compared with 96 s during the second scenario (p < 0.001). Checklist access had no significant impact on time to performance of emergency interventions, aside from shorter time to adequate glucose or glucagon administration (median times 632 s with, 756 s without checklist access; p = 0.03). CONCLUSION: Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting. Simply providing checklist access does not improve the performance of emergency interventions.KEY POINTSLittle is known about the factors that affect the performance of emergency interventions in the primary care setting.Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting.Simply providing crisis checklist access does not improve the performance of emergency interventions in the primary care setting.

[Esophageal-ECG in the emergency department]. / ABC om Esofagus-EKG.

The management of tachycardias depends on their underlying pathophysiology. The key to uncovering this pathophysiology is in finding the temporal relationship between atrial and ventricular activation. The P-waves resulting from atrial activation can however be hard to detect on a traditional EKG in the setting of a tachycardia. Esophageal-EKG can help reveal the P-waves. The patient swallows an electrode, whose position in the esophagus is then adjusted to maximize the signal coming from the left atrium, clearly revealing atrial activity. This article describes the indications and contraindications for esophageal-EKG, as well as how it is performed and interpreted. Esophageal-EKG is of particular diagnostic value in the setting of a regular tachycardia with wide QRS complexes and no obvious signs of atrio-ventricular dissociation. In this setting, the esophageal-EKG can distinguish between ventricular tachycardia and a supraventricular tachycardia with aberrant conduction.

Clinical use of an emergency manual by resuscitation teams and impact on performance in the emergency department: a prospective mixed-methods study protocol.

INTRODUCTION: Simulation-based studies indicate that crisis checklist use improves management of patients with critical conditions in the emergency department (ED). An interview-based study suggests that use of an emergency manual (EM)-a collection of crisis checklists-improves management of clinical perioperative crises. There is a need for in-depth prospective studies of EM use during clinical practice, evaluating when and how EMs are used and impact on patient management. METHODS AND ANALYSIS: This 6-month long study prospectively evaluates a digital EM during management of priority 1 patients in the Skåne University Hospital at Lund's ED. Resuscitation teams are encouraged to use the EM after a management plan has been derived ('Do-Confirm'). The documenting nurse activates and reads from the EM, and checklists are displayed on a large screen visible to all team members. Whether the EM is activated, and which sections are displayed, are automatically recorded. Interventions performed thanks to Do-Confirm EM use are registered by the nurse. Fifty cases featuring such interventions are reviewed by specialists in emergency medicine blinded to whether the interventions were performed prior to or after EM use. All interventions are graded as indicated, of neutral relevance or not indicated. The primary outcome measures are the proportions of interventions performed thanks to Do-Confirm EM use graded as indicated, of neutral relevance, and not indicated. A secondary outcome measure is the team's subjective evaluation of the EM's value on a Likert scale of 1-6. Team members can report events related to EM use, and information from these events is extracted through structured interviews. ETHICS AND DISSEMINATION: The study is approved by the Swedish Ethical Review Authority (Dnr 2022-01896-01). Results will be published in a peer-reviewed journal and abstracts submitted to national and international conferences to disseminate our findings. TRIAL REGISTRATION NUMBER: NCT05649891.

[Management of pneumothorax in the emergency department]. / ABC om Pneumotorax på akuten.

A couple of decades ago, most large pneumothoraces were managed initially through the insertion of large-bore chest tubes, active suction and in hospital admission. Mounting evidence has since established that the patient's symptoms, not the size of the pneumothorax, should guide whether invasive management is required for spontaneous pneumothoraces. There is also mounting evidence that small traumatic and iatrogenic pneumothoraces can be managed conservatively. Small-bore chest tubes are just as effective as large-bore chest tubes for all types of pneumothoraces and likely associated with fewer complications. Passive drainage allows for out-of-hospital follow-up for selected patients. This article presents a stepwise approach to the management of pneumothoraces in the emergency department based on a review of the current literature.

[Analysis of acid-base disturbances in the emergency department]. / ABC om Syra­bastolkning på akuten.

The analysis of acid-base disturbances contributes to the diagnostic work-up of critically ill patients. Most emergency departments are equipped with blood gas point-of-care analyzers that quantify within minutes pH, pCO2, standard bicarbonate, standard base excess, sodium and chloride levels. This article provides a pragmatic stepwise approach to the analysis of acid-base disturbances in the emergency department. Standard base excess is used to assess the adequacy of the secondary (compensatory) response. Calculation of the anion gap based on the actual bicarbonate is used to identify the coexistence of metabolic acidosis and metabolic alkalosis. The delta anion gap allows for the identification of measurement errors, such as falsely elevated lactate and chloride values, which in turn may provide diagnostic clues.

[Lung ultrasound promising method for assessing acute dyspnea and monitoring decompensated heart failure]. / Lungultraljud ­ en uppseglande metod vid dyspné och hjärtsvikt.

Ultrasound plays an important role in several medical fields. The heart was the first organ for which ultrasound gained clinical utility, followed by obstetric and gynecological applications. Shortly thereafter, abdominal organs and blood vessels became targets for ultrasound examination. The lung was long considered inaccessible for ultrasound due to its high air content. Work since the 1990s has however established a role for lung ultrasound, in leveraging several technical artefacts generated in the normal lung and in conditions with reduced air content, to allow rapid diagnosis of interstitial fluid accumulation, pneumothorax, pneumonia among others. In this article, we provide an overview of the potential of lung ultrasound, particularly as a promising method for assessment of patients presenting with acute dyspnea in the emergency department and for monitoring residual fluid in patients with decompensated heart failure. We also discuss limitations and caveats of the method.

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

BACKGROUND: Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown. METHODS: Eight crises (anaphylactic shock, life-threatening asthma exacerbation, haemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure) were simulated twice (once with and once without checklist access) in each of four EDs-of which two belong to an academic centre-and managed by resuscitation teams during their clinical shifts. A checklist for each crisis listing emergency interventions was derived from current authoritative sources. Checklists were displayed on a screen visible to all team members. Crisis and checklist access were allocated according to permuted block randomisation. No team member managed the same crisis more than once. The primary outcome measure was the percentage of indicated emergency interventions performed. RESULTS: A total of 138 participants composing 41 resuscitation teams performed 76 simulations (38 with and 38 without checklist access) including 631 interventions. Median percentage of interventions performed was 38.8% (95% CI 35% to 46%) without checklist access and 85.7% (95% CI 80% to 88%) with checklist access (p=7.5×10-8). The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. On a Likert scale of 1-6, most participants agreed (gave a score of 5 or 6) with the statement 'I would use the checklist if I got a similar case in reality'. CONCLUSION: In this multi-institution study, checklists markedly improved local resuscitation teams' management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.

[Approach to Weakness in the Emergency Department]. / ABC om Svaghet på akuten.

When assessing patients presenting with weakness to the emergency department, the initial focus is on determining whether patients are suffering from conditions where prompt treatment decreases morbidity and mortality.  Diagnosis is based on an understanding of neuroanatomy and on pattern recognition.  A structured history, combined with selected physical examinations and bedside tests, are used to formulate hypotheses regarding the anatomical location and nature of the underlying pathology.

[Swedish emergency physicians can safely sedate patients with propofol prior to cardioversion]. / Akutläkardriven propofolsedering är säker vid elkonvertering.

Emergency Medicine became a full-fledged speciality in Sweden in 2015. This prospective study analyzed the safety and implementation of Emergency Physician-administered propofol to sedate patients with hemodynamically stable atrial fibrillation prior to cardioversion. During the first 1.5 years, 321 sedations were carried out at Lund's Emergency Department by Emergency Physicians or senior residents. In two cases, the oxygen saturation dipped below 90% before responding to simple measures. In 12 cases, the systolic blood pressure dipped below 90 mmHg, and in two cases patients were administered a push-dose pressor. No patient required hospitalization due to sedation-induced complications. The majority of eligible specialists and senior residents voluntarily participated in an Emergency Physician-driven certification process. This study demonstrates the safety and feasibility of a locally implemented process for Emergency Physician-driven procedural sedation.

[The Swedish specialist examination in emergency medicine: reflections on the first decade]. / Svensk specialisttentamen i akutsjukvård: 10 års perspektiv - Med slutgiltigt mål att förbättra vården för patienterna på Sveriges akutmottagningar.

Emergency Medicine became a supraspeciality in Sweden in 2008. The Swedish Specialist Examination in Emergency Medicine is a formative examination that seeks to guide local training in Emergency Medicine, provide feedback to physicians during their residency, and establish national standards for various processes in Emergency Medicine. It consists of six partial examinations and 118 cases. Documents and checklists accessible on the internet specify the degree of competence expected during the examination. Program directors are tasked with offering the examination locally to their residents. During the past 10 years, the examination has been offered during 53 days to 180 residents belonging to 27 training programs. The total number of passed partial examinations is 201. Six physicians have so far passed all six partial examinations.

The Swedish specialist examination in emergency medicine: form and function.

AIM/BACKGROUND: The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine whether residents have attained the level of competence of specialists, but also to guide and facilitate residency training. METHODS: The Swedish Society for Emergency Medicine has developed checklists that delineate criteria of consideration and action items for particular processes. These checklists are freely available and used to assess competence during the examination. They are also intended for use during teaching and clinical care, thus promoting alignment between clinical practice, teaching and assessment. The examination is carried out locally by residency program educators, thereby obviating travel expenses. It consists of a total of 24 stations and over 100 potential scenarios, thereby minimizing case specificity. Each station consists of a scenario based on a real case. The checklists allow for direct feedback to the examinee after each station. RESULTS AND CONCLUSION: This model may be of interest to other European countries.

[Shock in the emergency department]. / ABC om - Chock på akuten.

Early recognition and management of shock decreases morbidity and mortality. The recognition of chock and identification of its causes is based on an integration of the clinical context, physical findings, history and bedside tests. Ultrasound plays an important role in elucidating the cause of chock in the emergency department (ED). This article presents a systematic approach to the patient presenting in shock to the ED and reviews the initial management of different causes of chock.

Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department.

In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions ('gestalt'). The aim of this study was to determine the diagnostic value of the ED physician's overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician's interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in ("Obvious ACS", LR 29) and at ruling out ("No Suspicion of ACS", LR 0.01) ACS. In the "Strong suspicion of ACS" group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.

[Dizziness in the emergency room]. / ABC om--Yrsel på akuten.

The majority of patients who present to the Emergency Department with vertigo suffer from benign conditions. However, a few percent of these patients have life-threatening conditions, such as a cerebellar stroke. The HINTS clinical decision rule (Head-Impulse test, Nystagmus, Test-of-Skew) allows the physician to identify patients with an acute vestibular syndrome of central origin. HINTS is more sensitive than early magnetic resonance imaging. There is no role for computed tomography in the evaluation of patients with isolated acute vestibular syndrome in the Emergency Department. For patients with benign paroxysmal positional vertigo, simple reposition maneuvers are effective for symptom relief.