Performance of the HEART, Emergency Department Assessment of Chest Pain Score (EDACS) and Vancouver Chest Pain Rule (VCPR) to identify low risk chest pain in the Emergency Department

Objective: Chest pain is a common Emergency Department (ED) presentation, but most patients will not have an Acute Coronary Syndrome (ACS). Decision tools have been developed to limit admissions to those at high risk of ACS, whilst allowing safe discharge of those at low risk. We aimed to evaluate the performance of three international decision tools (HEART, EDACS and VCPR) in the local setting. Design and Methodology: A prospective, observational cohort study was conducted to include ED patients presenting with low/intermediate risk chest pain. Participants were followed up at 6 weeks for Major Adverse Cardiac Events (MACE). Performance of clinical gestalt and the 3 scores were estimated. Results: 537 patients were enrolled, with 12 lost to followup, leaving 525 for analysis. Six patients developed MACE (1.14%). HEART had sensitivity, 16.67% (95% CI; 0.42% - 64.12%); specificity, 96.15% (95% CI; 94.11% - 97.63%); negative likelihood ratio (NLR), 0.87 (95% CI; 0.61 ­ 1.24). EDACS had sensitivity, 16.67% (95% CI; 0.42% - 64.12%); specificity, 95.38% (95% CI; 93.2% - 97.02%); NLR, 0.87 (95% CI; 0.61 ­ 1.25). VCPR had sensitivity 83.33% (95% CI; 35.88% - 99.58%); specificity, 67.05% (95% CI; 62.82% - 71.09%); NLR, 0.25 (95% CI; 0.04 ­ 1.49). Clinician gestalt had sensitivity 16.67% (95% CI; 0.42% - 64.12%); specificity, 97.5% (95% CI; 95.75% - 98.66%); NLR, 0.85 (95% CI; 0.6 ­ 1.22). Conclusion: In local patients with chest pain, the VCPR performed best for identifying patients for safe discharge, as well as with the lowest risk of MACE. The HEART, EDACS and clinical gestalt appear to be poorer decision tools.

Determination of risk factors associated with adverse outcomes of thrombolysis in acute ST Elevation Myocardial Infarction (STEMI)

Objective: Thrombolysis is the standard treatment for STEMI in most developing countries. However, adverse events attributable to thrombolysis occur, and must be considered in risk -benefit decisions. We aimed to estimate the local incidence of thrombolysis complications, whilst determining factors predisposing to adverse outcomes. Design and Methodology: A multicentre, prospective, observational cohort study was conducted; including consecutive adults with STEMI presenting to 3 Emergency Departments (EDs). Primary outcomes were complications and 30-day mortality. Results: 236 participants were enrolled (78.0% Indo- Trinidadian; 72.9% Male; 46.2% Hypertensive; 44.9% Diabetic; 57.9% Smokers). 27.5% of patients experienced complications; mainly a c u t e h e a r t f a i l u r e ( AHF) (8.5%) and cardiogenic shock (8.1%). In-hospital and 30-day mortality rates were 5.9 % and 9.2% respectively. Adverse outcomes of thrombolysis occurred in 9 (3.8%) patients (one intracerebral haemorrhage). No deaths were directly attributable to thrombolysis. No risk factor correlated with complications of thrombolysis, however a t r i o v e n t r i c u l a r ( AV) block (OR 9.73, CI 1.70 - 55.87, p = 0.011) and b l o o d u r e a n i t r o g e n ( BUN) (OR 1.09, CI 1.04 - 1.14, p < 0.001) were associated with increased in hospital mortality. Age ≥ 75 (OR 16.72, CI 1.45 - 192.44, p = 0.024), Systolic blood pressure (SBP) (OR 0.97, CI 0.96 - 0.99, p = 0.009) and BUN (adjusted OR 1.08, CI 1.03 - 1.13, p = 0.002) correlated with increased 30-day mortality. Conclusion: Thrombolysis for STEMI was associated with a low incidence of adverse events and similar mortality to developed nations. No factor was associated with adverse outcomes, although older age, high BUN, low SBP or AVB increased mortality risk. These findings can guide local physicians counselling patients/relatives regarding thrombolysis for STEMI.

Medical Utilisation at a Major Sporting Event ­ a descriptive & epidemiological analysis

Background: Medical utilisation and contacts at amateur/international sporting events is an accepted phenomenon, as evidenced by mandatory medical coverage requirements for major events. There is little data however, on the volume and type of contacts expected outside of elite sport. This may lead to inefficient resource allocation and pose challenges to organisers in planning and delivery of medical services. In addition, data on contacts may assist in targeted preventative strategies. Objectives: We aimed to measure resource utilisation at the largest international aquatic sporting event in the hemisphere. We also aimed to measure epidemiological data including the type, location, sporting discipline and outcomes of medical contacts during the event. Methods: This was a prospective observational study conducted under the auspices of the organising committee of the XXX Confederation Centroamericana y del Caribe de Natacion (CCCAN) championships held in Trinidad & Tobago. Anonymised data was collected from event medical contact records, screening and voluntarily reported contacts by team medical staff (for individuals who did not visit event medical staff). We excluded contacts by spectators. Data was collected over a 12 day competition period. Descriptive analysis was undertaken using Microsoft Excel. Injury incidence rate (IR; number of injuries per 1000 athlete-days) and injury incidence proportion (IP; injuries per 100 athletes) were calculated. Results: There was a total of 5037 athlete/official days. There were 110 medical contacts for the event, with 80 occurring in athletes (72.7%). A significant number of non-sport related contacts was observed (60% of total) with a high number of complaints related to exhaustion and inadequate hydration. This was independent of country of origin. Acute gastroenteritis, ear and sinus infections were within expected frequencies. No EMS usage was necessary, and hospital transfers were for diagnostics in all cases. Open water swimming was associated with the most contacts, followed by water polo and swimming. Two-thirds of hospital transfers were for water polo associated injury. There were a total of 54 sport related contacts in 3956 athlete days (IR 13.65 injuries per 1000 athlete-days with an injury incidence proportion, IP; of 6.5 per 100 athletes). Conclusions: Planning for aquatic events must take into consideration non-sport as well as competition related complaints. This study gives important information on medical utilisation for future event planning.

ST elevation Myocardial Infarctions at a rural Emergency Department ­ 4 year experience in South Trinidad

Background: ST elevation Myocardial Infarctions (STEMIs) are one of the most common treatable causes of death and morbidity in Trinidad & Tobago. Bodies such as the American Heart Association (AHA) have recognised that early identification and treatment using thrombolytics or Primary Coronary Intervention (PCI) of STEMIs is crucial to improving patient outcomes, and have made recommendations for ideal critical actions in the management of STEMIs. Data on the performance of Emergency Departments to deliver these actions is poor in many developing countries, but at the same time, are important to measure in order to drive improvement in patient care. Objectives & Methods: We aimed to determine the quality metrics and six (6) month mortality outcomes in STEMI patients who presented to the Emergency Department, Siparia District Health Facility. Medical records for all patients receiving thrombolytic therapy were obtained over the period January 2011 ­ December 2014. Data was extracted and reviewed and 6 month telephone follow-up via was performed for these patients. Descriptive analysis was undertaken using Microsoft Excel. Results: Seventy- seven (77) patients received thrombolysis but only sixty-one (61) had complete documentation. There were almost 4 times as many men than women (77.8% of males and 20.3% of females), with the mean ages being 58.8 years and 66.1 years respectively. The most common risk factor was hypertension, followed by diabetes mellitus. The most common type of STEMI was of the inferior wall. The median Door to ECG time was 10 minutes with 52.5% of patients achieving a Door to ECG time of less than 10 minutes. The median Door to Needle time was 70 minutes with only 8.2% of patients having a Door to needle time of less than 30 minutes. Approximately half of all patients thrombolysed showed greater than 50% ECG resolution. 94.3% of patients were alive at 6 months. Conclusions: Although the AHA recommended standards for thrombolysis were not met fully, these results show that despite the limitations of practice in a rural developing world setting, the majority of patients received timely and appropriate care. Although showing better performance than other local centers, changes within the system are still required to meet first world standards, improve patient care and potentially improve mortality. Hypertension and Diabetes are major risk factors in our population.

An Exploratory Analysis of Referrals to a major Emergency Department in a developing country

Background: Hospital crowding, ED waiting times and high demand for unscheduled care all place significant burdens on secondary care services. This impacts on patient care, staff morale and overall functioning of the whole healthcare system. Patient referrals from other healthcare providers often is a result of limited access to resources, specialists or because of acuity. However, some referrals may be more suitable for lower acuity settings, with the benefit of better overall patient experience. In addition, duplication of contacts with a healthcare professional may not result in additional benefit to patients, but may necessarily add to the patient journey and contribute to crowding. Objectives: We aimed to determine the originator of referrals to the ED. We also aimed to determine the proportion of referred patients who received any meaningful intervention at the ED. Finally, we aimed to estimate the proportion of patients referred who may have been suitable for direct inpatient referral or management in a lower acuity setting. Methods: We conducted a prospective evaluation of all referrals to the ED of a large urban hospital over 7 days. Routine anonymised demographic, diagnosis and intervention data were collected and simple descriptive analysis was undertaken using Microsoft Excel®. A validated algorithm was applied to determine suitability for lower acuity settings, and contextual secondary analysis was applied to determine choice of altResults: There were 168 formal referrals during the period evaluated (mean 24/day), of which data was available for 151. Most referrals were on Monday and Thursday. 39.7% were referred from the four regional District Health Facilities (DHF). 12 % were referred by specialists. There were significantly higher referrals from Local Health Centres located more than 5km of the hospital compared with those closer, although this could have been due to greater numbers outside the 5 km radius. 5.5% were thought suitable for primary care management and 31% could have been referred directly to an inpatient team if this were available. The majority (51.3%) of referred patients received no significant intervention in the ED, with almost 1 in 7 suitable for outpatient management. Conclusions: A significant number of patients referred to the ED may have been more appropriately directed. Direct special admission, access to outpatient referral slots or telephone advice from senior ED or specialty clinicians may prevent up to a half of referrals being seen by an ED clinician. This may reduce unnecessary transport, improve time and resource utilization and decongest the ED and hospital. Further large scale evaluation is warranted to investigate the predictors of referral, control for seniority, and make more robust recommendations for improving the patient journey ernate pathways.

Does pre-existing medical conditions and pre-competition screening identify athletes at risk of medical intervention in competitive Open Water swimming?

Background: Open water swimming is one of the fastest growing mass participation sports worldwide. Analysis of triathlon deaths and cardiac arrests have shown that 75% of these occur in the swimming leg. Less than half had autopsy evidence of cardiac disease, and swimming ability or medical conditions do not appear responsible. Mandatory pre-competition clinical screening has been traditionally promoted in open water swimming to identify athletes at risk of illness or death during competition. The variable nature of this screening however, may not be useful in identifying at risk individuals. Objectives: We aimed to determine whether the presence of pre-existing medical conditions or abnormalities discovered on clinical screening [blood pressure (BP), heart rate (HR), auscultation of heart and lungs and apical palpation] predicted either failure to complete the race or the need for medical contact. Methods: We collected screening and competition data from participants in the two largest regional Open Water competitions in 2017 ­ including international (CCCAN) and mixed ability (ASATT Maracas) athletes. Anonymised data on event medical contacts, failure to finish and screening were analysed, with descriptive results and risk ratios calculated using MedCalc statistical software. Age adjusted values for BP and HR outside the 90th centile was considered abnormal. Results: Overall, 410 athletes participated for which data was available for 400 (mean age 17.9 years, range 7-79; 58% male). There were 30 medical contacts, of which 22 were unable to complete the race. There was no significant sex difference in those unable to complete. The majority of contacts was for the 10k race (60%) with the 5k (23%) the next most common. The most common reason for non-completion was exhaustion. Three scratched due to illness on competition day. 21 athletes were asthmatic, and 2 had cardiac murmurs, however all completed their respective races and none required any medical contact. Asthma (RR 0.3, p=0.39), abnormal physiological measurements (RR 1.32, p=0.84) and other medical conditions (RR 0.94, p=0.96) did not appear predictive. Current illness was the only significant predictor of failure to complete or medical contact. (RR 6.67; 95% CI 2.36 -18.84), however a larger sample may be necessary to show significance. Conclusions: There is much variability in pre-competition screening for Open Water swimming, as with other sports. Intuitively, only current illness predicts failure to complete/medical contact, although it is unclear whether this can be used as a surrogate for athletes at risk of more serious sequelae. Pre-existing medical conditions such as asthma do not appear to be contributory to non-completion, nor does moderately abnormal physiological measurements. Given that cardiac arrythmias or structural abnormalities are implicated in some deaths during open water swimming, adding resting electrocardiography and possible echocardiography to pre-participation medical examination may be reasonable, however the effectiveness of this strategy is disputed. There appears to be little benefit in clinical screening immediately prior to competition, with a more thorough, structured pre-training examination likely to be superior.

Performance of Sepsis Scoring Systems in a developing country ­ a prospective cohort study

Background: Sepsis and its sequelae poses a significant socio-economic burden on health care systems globally. Risk stratification plays a fundamental role in emergency department management, since early and aggressive management in high-risk cohorts leads to improved outcomes. Several risk stratification tools exist but in the local setting (developing country with high chronic disease burden) there is no standardised recommendation for beside utilisation. Objectives: We aimed to compare the ability of the quick Sepsis-related Organ Failure Assessment (qSOFA) score with the Systemic Inflammatory Response Syndrome (SIRS) criteria and National Early Warning Score (NEWS) to detect and risk stratify patients with presumed sepsis outside of the intensive care unit (ICU). Methods: A prospective observational cohort study was conducted at a public tertiary hospital during the period May to June 2017. Ethical and institutional approval was secured and informed consent was sought from study participants aged eighteen (18) years and older. Demographic and clinical data were collected via a data collection instrument and statistical analysis was undertaken using IBM SPSS v23. Results: 304 patients were treated for presumed sepsis. The primary outcomes of in-hospital death or intensive care unit admission were seen in 14.8%. Discrimination for the primary outcome was highest for NEWS (AUROC 0.88 [95% CI 0.83-0.94]) followed by qSOFA (AUROC 0.82 [95% CI 0.74-0.89]) and SIRS (AUROC 0.69 [95% CI 0.61-0.77]). A NEWS value of ≥4 resulted in a sensitivity of 93.3%, and negative predictive value of 98.3% (p<0.001). A qSOFA score ≥2 demonstrated a specificity of 94.6 % and a negative predictive value of 91.4% (p<0.001). A SIRS criteria score ≥2 resulted in a sensitivity of 88.9%, and a negative predictive value of 95.0% (p=0.001). Univariate analysis showed that: need for supplemental oxygen, an oxygen saturation less than 91%, a Glasgow Coma Scale <15 and non-selfpresentation were associated with the highest odds ratios for death in-hospital or ICU admission. Conclusions: Urgent identification of high-risk patients with presumed infection is critical in achieving a positive outcome. NEWS was superior to both qSOFA AND SIRS in predicting in-hospital mortality and need for ICU admission A qSOFA score ≥2 demonstrated a high specificity but poor sensitivity, thus limiting its use as a bedside tool. The findings of this study are consistent with the Sepsis-3 guidelines, which recommend qSOFA as being superior to SIRS criteria. However, we found that NEWS had a superior predictive value to both. Its role in the identification of high-risk subjects should be further evaluated.