Outcomes of Patients with a pH<7.0 Presenting to the Emergency Department (OPpHED Study).

Objectives The aim of this study was to assess the mortality and predictive factors in patients presenting with a pH<7.0 to the emergency department (ED). Methods A retrospective study of patients presenting to the ED of University Hospital Galway with a pH<7.0 from January 2014 to December 2017 was performed. A pH<7.0 on arrival to the ED from either an arterial or venous sample as measured by the blood gas analyser machine were assessed for inclusion. Results A total of 130 patients presented to ED over a 4-year period, with a mean age of 58 ±20 years. Eighty-one (63%) patients of the total cohort were male. In terms of aetiology of presentation, 66 (51%) cases were from cardiac arrest (CA), while the remaining 64 (49%) cases were non-cardiac arrest (NCA) related. Twenty-eight-day mortality was 69.5% overall, with significant mortality in the CA group (89%) compared to the NCA group (48%) (p<0.00). A modified early warning score (MEWS) (odds ratio [OR] 1.37, 95% CI: 1.18-1.59) and PCO2 ([OR] 1.35, 95% CI: 1.08-1.68.) were predictive of mortality. Conclusion In patients presenting to the ED with a pH of <7.0 the overall mortality was 69.5%, with survival more likely in NCA aetiologies. Mortality was associated with higher pCO2 and MEWS.

Ultrasound as a Diagnostic Tool in Paediatric Distal Forearm Fractures

Aims To evaluate the accuracy of ultrasound in pediatric distal forearm fractures as well as the effect on the ED waiting time for these patients. Methods Convenience sample of 42 pediatric patients presented with wrist injury. All patients underwent US examination followed by 2-views radiographs of the wrist with recording the time to US. In addition, the time to X-ray were calculated, retrospectively, on 95 pediatric patients for comparison. Results Forty-two patients were examined, 25 males (60%) and 17 females (40%), mean age 7.2 years. On X-Ray, 30 patients (71%) were confirmed to have a distal forearm fractures, of which, 28 (93%) were diagnosed by US. The sensitivity of ultrasound diagnosis was 93.3% (95% CI, 83%-100%), and the specificity was 92% (95% CI, 76%-100%). The positive and negative likelihood ratios were 11.6 and 0.07, respectively. Conclusions Ultrasound is a reliable diagnostic tool in the diagnosis of distal forearm fractures in children. Ultrasound has radiation free and decreases the length of stay in ED.

The needle catcher--a safer way to suture.

The needle catcher is a novel surgical instrument which has been developed in Belfast in conjunction with Queen's University Belfast that aims to reduce suture needle exposure and increase operator safety during suturing. The instrument was used to close wounds in 20 patients presenting to A&E in the Royal Group of Hospitals and to the plastic surgery service in the Ulster Hospital. This letter includes a technical description of the instrument, evaluation of needle exposure, comments from users, evaluation of the needle catcher and a discussion on the need for additional protection for medical staff in surgical based specialties where there is frequent exposure to blood, open wounds and sharps.

Team triage improves emergency department efficiency.

OBJECTIVE: To see whether three hours of combined doctor and nurse triage would lead to earlier medical assessment and treatment and whether this benefit would carry on for the rest of the day when normal triage had resumed. METHOD: Eight days were randomly selected; four for team triage and four for the normal nurse led triage. Team triage was coordinated by a middle grade or consultant from 9 am to 12 noon. Times to triage, to see a doctor, radiology, admission, and discharge were recorded. No additional medical or nursing staff were used and staffing levels were similar each day. All patients including blue light emergencies and minor injuries were included. RESULTS: Median times were significantly reduced (p<0.05) during the intervention to triage (2 min v 7 min, p = 0. 029), to see a doctor (2 min v 32 min, p = 0.029), and to radiology (11.5 min v 44.5 min, p = 0.029). Waiting times at midday were longer for patients in the non-intervention group. More patients were seen and discharged within 20 minutes in the intervention group (18 of 95 (19%) v 2 of 69 (3%) p = 0.0043). No significant knock on effect was demonstrable for the remaining 21 hours after the intervention ceased. CONCLUSION: Three hours of combined doctor and nurse triage significantly reduces the time to medical assessment, radiology, and to discharge during the intervention period. Waiting times at midday were shorter in the triage group. There was no significant knock on effect the rest of the day.

Non-touch suturing technique fails to reduce glove puncture rates in an accident and emergency department.

OBJECTIVE: To assess the impact of introducing a safer non-touch suturing technique into an inner city emergency department. METHODS: The rate of glove perforation, measured by electrical conductance, was used as a marker. Gloves (Bodyguards) used in suturing were collected over a two month period. Two half day suture workshops were then conducted in the emergency department and gloves were collected for a further two months. All doctors (14) were included in the study regardless of grade. Gloves were tested for perforation by electrical conductance. RESULTS: There were 107 gloves and 19 perforations in the first group, 133 with 28 perforations in the second (p = 0.52), and one perforation in 100 control gloves. Most doctors reported inadvertent needlestick handling. CONCLUSION: Two half day suturing workshops are not enough to reduce glove perforations from suturing in the emergency department. Difficulty with compliance suggests that safe suturing practice must be taught before doctors develop bad habits that are difficult to change.

Are we getting the point? Needlestick injuries-an ongoing problem.

The pattern of glove perforation using hollow needles is unknown and the incidence, using sensitive electronic methods has not been described. We wished to identify the glove perforation rate following the use of hollow needles in our Emergency Department. Two hundred and eighty-nine gloves were collected over three months. These gloves were electronically tested and compared with one hundred unused control gloves. There were 28/298 perforations (9.7%) vs 1/100 in the control group (P<0.01 Fisher's exact probability). Most perforations were located on the thumb and index fingers. There were no needlestick injuries reported during this period. The glove perforation rate following hollow needle use in our Emergency Department is higher than previously reported. The pattern of perforation suggests injury by the needle held in the dominant hand.

Transfer of telemedical support to Cornwall from a national telemedicine network during a solar eclipse.

During late 1998 and early 1999, planning officers in Cornwall predicted a huge increase in summer visitors to the county to observe the August solar eclipse. There was the possibility that a mass gathering in Cornwall could overload existing arrangements for handling accident and emergency patients. We therefore set up a telemedicine system to support the county's minor injury units (MIUs) from hospitals throughout the UK. Six main hospital accident and emergency departments outside Cornwall with existing links to their own MIUs were twinned with 10 of the 11 MIUs in Cornwall before the expected date of the gathering. The network was live for nine days, starting four days before the eclipse, and 2045 patients were seen in the 10 MIUs. There were 93 telemedicine calls from the 10 MIUs, involving 91 patients. Overall, 4.6% of the patients required a telemedicine consultation. Fifty-seven calls were made during working hours. Thirty-four patients were referred for further management, of whom 18 were referred on the same day. The transfer of telemedical support to a national network was successful.

Markers for domestic violence in women.

OBJECTIVE: To determine injury patterns and characteristics specific to domestic violence in women who present to the accident and emergency (A&E) department. DESIGN: A retrospective case note review of all female assaults over a one year period. The subjects were women who disclosed that their injuries were due to assaults by either a current or a previous male partner. Controls were female assault victims not injured by domestic violence. SETTING: A medium sized urban A&E department. RESULTS: There were 500 female assaults out of 48,169 new attendances. Domestic violence was disclosed in 103 cases. The following features were significantly associated with domestic violence in women: multiple injuries (p < 0.001) (especially to the head and arms), fractures (p < 0.05), loss of consciousness (p < 0.05), abdominal injuries (p < 0.05), pregnancy (p = 0.01), injury occurring on "stairs" (p = 0.01), and general practitioner referral (p < 0.01). CONCLUSIONS: Women who have been assaulted are more likely to have been injured during domestic violence if they sustain multiple injuries (including fractures), abdominal injuries, have lost consciousness, or have been referred by their general practitioner. These markers may help medical staff to identify more cases of undisclosed domestic violence. The markers need to be tested further in a prospective study.

Telemedicine and cardiopulmonary resuscitation: the value of video-link and telephone instruction to a mock bystander.

We evaluated cardiopulmonary resuscitation (CPR) performed by persons with no previous experience on a resuscitation dummy. Subjects were randomized into four groups, one of which had no instruction. The other three groups were instructed for 3 min in mock CPR by a supervisor using a telephone, a video-link, or directly in person. They were compared with a group which had had previous CPR training. The main outcome measures were the number of correct ventilations, chest compressions and compressions with correct hand position. Video-link instruction was associated with significantly higher median scores for all three outcome measurements (P < 0.05), whereas telephone instruction and previous CPR training were associated with higher scores on only one, namely ventilations (P < 0.05). Video-link instruction was comparable with direct observer instruction. There was no significant difference between previously trained subjects and the intervention groups. Video-link instruction can produce significant improvements in the quality of CPR in mock resuscitations for persons with no resuscitation training.

Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and the Republic of Ireland.

OBJECTIVES: To determine the incidence of verbal abuse and physical violence in accident and emergency (A&E) departments and to discover the extent of provision of security measures and instructions for staff on how to deal with these problems. DESIGN: A postal questionnaire. SETTING: A&E departments in the UK and the Republic of Ireland. SUBJECTS: Two hundred and seventy three consultants named in charge of 310 departments. MAIN OUTCOME MEASURES: Frequency of physical violence and verbal abuse, injuries sustained, perceived precipitating factors, security measures instituted, and legal action taken. RESULTS: Two hundred and thirty three replies were received. Alcohol, waiting times, recreational drug usage, and patients' expectations were perceived as the chief causes. Patients were the chief perpetrators with nurses being the commonest victims. Staff sustained 10 fractures, 42 lacerations, and 505 soft tissue injuries. There were 298 arrests and 101 court appearances that resulted in 76 convictions. Panic buttons and video cameras were the most common security measures. CONCLUSIONS: Staff within A&E departments are regularly abused, both verbally and physically. Inner city departments appear to be most affected. Documentation is poor. Perpetrators are seldom convicted. There do appear to be actions which hospitals could undertake that might help to ameliorate these problems.

Coeliac disease in Galway, Ireland 1971-1990.

Recent studies have reported changes in the incidence of coeliac disease and in its presentation. We carried out a retrospective study looking at the incidence and clinical features of coeliac disease in Galway children over a 20 year period. The study period was divided in two parts. (I) Patients diagnosed between 1971 and 1980 and (II) between 1981 and 1990. Comparison was made between demographic and clinical data in these two periods. There were 97 cases of coeliac disease diagnosed in children resident in Galway over the 20 year period. 71 patients were diagnosed in period I and 26 in period II. The median age at diagnosis in period I was 1.41 years and 4.95 years in period II. There were more females diagnosed in period I. Growth data, histology and enzyme levels were similar in both groups. Diarrhoea and vomiting were the major presenting symptoms in both periods but more patients presented with wasting or abdominal protuberance in the latter period. Our data support the concept that coeliac disease in childhood is declining, and is presenting at a later age.