Emergency Department Patients Who Leave Before Treatment Is Complete.

INTRODUCTION: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. METHODS: This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. RESULTS: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. CONCLUSION: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.

In-flight Medical Emergencies.

In 2018, approximately 2.8 million passengers flew in and out of U.S. airports per day. Twenty-four to 130 in-flight medical emergencies are estimated to occur per 1 million passengers; however, there is no internationally agreed-upon recording or classification system. Up to 70% of in-flight emergencies are managed by the cabin crew without additional assistance. If a health care volunteer is requested, medical professionals should consider if they are in an appropriate condition to render aid, and then identify themselves to cabin crew, perform a history and physical examination, and inform the cabin crew of clinical impressions and recommendations. An aircraft in flight is a physically constrained and resource-limited environment. When needed, an emergency medical kit and automated external defibrillator are available on all U.S. aircraft with at least one flight attendant and a capacity for 30 or more passengers. Coordinated communication with the pilot, any available ground-based medical resources, and flight dispatch is needed if aircraft diversion is recommended. In the United States, medical volunteers are generally protected by the Aviation Medical Assistance Act of 1998. There is no equivalent law governing international travel, and legal jurisdiction depends on the patient's and medical professional's countries of citizenship and the country in which the aircraft is registered.

Patient Reported Experience on Consenting for Surgery - Elective Versus Emergency Patients.

INTRODUCTION: Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings. METHODS: Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05. RESULTS: A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65). CONCLUSION: This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making.

First look at emergency medical technician wellness in India: Application of the Maslach Burnout Inventory in an unstudied population.

INTRODUCTION: Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India. METHODS: This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages. RESULTS: Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year. CONCLUSION: This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources.

School Nurses' Perceived Barriers and Perceptual Influences When Implementing AED Programs.

School nurses' experienced barriers and benefits with perceptions of self-efficacy are important factors to consider for program implementation in the school setting. Little research has been done in the area of automated external defibrillator (AED) program implementation by the school nurse for the treatment of sudden cardiac arrest. The purpose of this study was to identify benefits of and barriers to AED program implementation in public schools and measure school nurses' self-efficacy related to their role as a change agent in program implementation. Results revealed that school nurses are functioning with a high level of self-efficacy in their ability to influence major health-care decisions in the school setting, and despite barriers, AED program implementation is considered beneficial and a necessary component of emergency care.

Ansiedad parental y factores asociados en urgencias pediátricas hospitalarias, un estudio descriptivo transversal / Parental anxiety and associated factors in pediatric hospital emergencies, a cross-sectional descriptive study

OBJETIVO: Las Urgencias hospitalarias pediátricas han aumentado notablemente en los últimos años, produciendo un uso irracional y la sobremasificación de las mismas. El objetivo de este estudio fue evaluar el nivel de ansiedad y los factores asociados en los padres y madres que acudían con sus hijos a Urgencias. MEÉTODOS: Se realizó un estudio descriptivo transversal con una muestra de 200 padres y madres que demandaban asistencia en un hospital de nivel 3 de Valencia (España), durante los meses de marzo, abril y mayo de 2019. También se estimó la fiabilidad de la escala State-Trait Anxiety E-7 (STAI-E7). Los datos se obtuvieron a partir de un documento autoadministrado y diseñado para tal fin. Se recogieron datos relacionados con el nivel de ansiedad y las posibles variables predictoras relacionadas con los padres y con los niños. El análisis de los datos obtenidos se realizó mediante el programa estadístico Statistical Package for the Social Sciences (SPSS, versión 20.0 para Windows) y la regresión ordinal con el programa estadístico R commander. RESULTADOS: Un 75,5% de las personas que acudieron con sus hijos a Urgencias hospitalarias eran madres y un 24,5% padres. La puntuación media obtenida respecto al nivel de ansiedad de la muestra fue moderada (9,18±4,92). Las madres presentaban cifras más elevadas que los padres (9,7±4,8 y 7,5±5,1, respectivamente). La probabilidad de sufrir un mayor nivel de ansiedad en las madres se multiplicaba por dos (OR=2,286; IC 95%: 1,212-4,353; P=0,01) respecto a los padres. La escala STAI-E7 presentó una buena consistencia interna (alfa de Cronbach=0,847). CONCLUSIONES: Las madres presentan cifras más elevadas de ansiedad. Se valora la necesidad de realizar más estudios para cuantificar los niveles de ansiedad parental en el ámbito de Urgencias, con el propósito de crear herramientas y programas para disminuirla

OBJECTIVE: Pediatric hospital emergencies have increased hardly in the recent years, product of the irrational use and the over-massification. The objective of this study was to evaluate the relationship between anxiety and sociodemographic factors of the parents and mothers. METHODS: Descriptive cross-sectional study on parental anxiety and associated factors in a pediatric hospital emergency service with sample n=200 fathers and mothers who demand care in a level 3 hospital in Valencia. (Spain), during march, april and may of 2019. It was estimated the reliability of the Anxiety Scale E-7 (STAI-E7). The data was obtained with a self-administrated and desired document for the purpose. Data related to the level of anxiety and possible predictive variables were collected. The analysis of the data obtained was performed with the Statistical Package for the Social Sciences program (SPSS, version 20.0 for Windows) and ordinal regression with the R commander program. RESULTS: The results show that 75.5% of the people who went to the hospital with their children were mothers and 24.5% were fathers. The mean score obtained regarding the level of anxiety in the sample is moderate (9.18±4.92). Mothers present higher levels of anxiety than fathers (9.7±4.8 and 7.5±5.1, respectively). The probability of experiencing a higher level of anxiety in mothers is multiplied by two (OR=2.286; 95% CI: 1.212-4.353; P=0.01) compared to parents. The STAI-E7 scale presents a good internal consistency (Cronbach's Alpha=0.847). CONCLUSIONS: Mothers have higher levels of anxiety. It will be appreciated doing more studies to quantify the levels of parental anxiety, with the purpose of creating tools and programs to decrease it

What older people want from emergency care: a systematic review.

OBJECTIVES: To evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers. METHODS: A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively. RESULTS: Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty. CONCLUSION: The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals' preferred outcomes could improve person-centred care. PROSPERO REGISTRATION NUMBER: CRD42018107050.

Patient satisfaction with peri-operative anesthesia care and associated factors at two National Referral Hospitals: a cross sectional study in Eritrea.

BACKGROUND: Measuring patient satisfaction has become an important parameter of the continuous quality assessment and improvement in anaesthesia services. The aim of this study was to assess the level of patient satisfaction with perioperative anaesthesia care and to determine the factors that influence satisfaction. METHOD: This study is an cross sectional design, conducted on 470 patients who underwent different types of surgeries at two National Referral Hospitals in Asmara, Eritrea between January and March of 2018. Patients were interviewed 24 h after the operation using a Tigrigna translated Leiden Perioperative Care Patient Satisfaction questionnaire (LPPSq). Descriptive and inferential analysis were made using SPSS (version 22). Statistical significance level was set at P < 0.05. RESULTS: The overall satisfaction score was 68.8%. Less fear and concern was observed among patients with satisfaction scores of 87.5%. Staff-patient relationship satisfaction score was 75%. Patients were least satisfied with information provision (45%). Multivariable analysis revealed that satisfaction of patients who did surgery at Halibet hospital is significantly higher (p < 0.001) than those patients who did at Orotta hospital. Moreover, those patients who did elective surgery had higher level of satisfaction that those who did emergency surgery (p < 0.001). CONCLUSION: Moderate level of satisfaction was observed among the patients. Generally, the study emphasized that the information provision about anesthesia and surgery was low. Patients described better staff-patient relationship and low fear and concern related to anesthesia and surgery was observed.

Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis.

BACKGROUND: To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary. METHODS: We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses. RESULTS: Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers. CONCLUSIONS: In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BACKGROUND: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. METHODS: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. RESULTS: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. CONCLUSIONS: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Adolescent perspectives about their participation in alcohol intervention research in emergency care: A qualitative exploration using ethical principles as an analytical framework.

AIMS: To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care. METHODS: In-depth semi-structured interviews with 27 adolescents (16 males; aged 14-17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis. RESULTS: Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves. CONCLUSIONS: Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence. TRIAL REGISTRATION: ISRCTN Number: 45300218.

Women's psychosocial outcomes following an emergency caesarean section: A systematic literature review.

BACKGROUND: Given the sudden and unexpected nature of an emergency caesarean section (EmCS) coupled with an increased risk of psychological distress, it is particularly important to understand the psychosocial outcomes for women. The aim of this systematic literature review was to identify, collate and examine the evidence surrounding women's psychosocial outcomes of EmCS worldwide. METHODS: The electronic databases of EMBASE, PubMed, Scopus, and PsycINFO were searched between November 2017 and March 2018. To ensure articles were reflective of original and recently published research, the search criteria included peer-reviewed research articles published within the last 20 years (1998 to 2018). All study designs were included if they incorporated an examination of women's psychosocial outcomes after EmCS. Due to inherent heterogeneity of study data, extraction and synthesis of both qualitative and quantitative data pertaining to key psychosocial outcomes were organised into coherent themes and analysis was attempted. RESULTS: In total 17,189 articles were identified. Of these, 208 full text articles were assessed for eligibility. One hundred forty-nine articles were further excluded, resulting in the inclusion of 66 articles in the current systematic literature review. While meta-analyses were not possible due to the nature of the heterogeneity, key psychosocial outcomes identified that were negatively impacted by EmCS included post-traumatic stress, health-related quality of life, experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the most commonly examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptoms and diagnosis. CONCLUSIONS: EmCS was found to negatively impact several psychosocial outcomes for women in particular post-traumatic stress. While investment in technologies and clinical practice to minimise the number of EmCSs is crucial, further investigations are needed to develop effective strategies to prepare and support women who experience this type of birth.

Patients who leave Emergency Department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short term outcomes.

BACKGROUND AND AIMS: Patients who leave Emergency Department before physician's visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients. METHODS: This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients. RESULTS: The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician's visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5-4.7; OR = 2.89, 95%CI 2.8-2.9; LDT: OR = 3.12, 95%CI 3-3.2; OR = 2.25, 95%CI2.2-2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4-3.9; OR = 2.25, 95%CI 2.1-2.4; LDT: OR = 3.96, 95%CI 3.6-4.3; OR = 2.62, 95%CI 2.4-2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6-4.2; OR = 1.7, 95%CI 1.3-2.2 within 2 and 7 days respectively). CONCLUSIONS: Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with.

Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review.

QUESTION: What are staff and patients' perceptions of physiotherapists working in the emergency department (ED)? DESIGN: Systematic review of qualitative studies. PARTICIPANTS: Staff working in EDs and patients presenting to the ED and managed by ED physiotherapists. OUTCOME MEASURES: Perceptions of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction, grouping (codes), and abstraction of findings. RESULTS: Eight studies, which had sought the perceptions of 138 patients and 122 ED staff members, were included. Three main themes emerged: role of physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education, non-pharmacological pain management and activity resumption, especially through exercise therapy. Having broad knowledge to assess and treat different health conditions was seen as facilitating the work of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal communication skills. ED staff expressed concerns regarding the additional time that physiotherapists spent with patients. Some patients felt that performing exercises in the ED was inappropriate and painful. CONCLUSIONS: ED physiotherapists were mostly well accepted by patients and ED staff, and their work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira GE, Traeger AC, O'Keeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy 64: 229-236].

Dyspnoea and self-management strategies in patients admitted to the emergency department: A study of patients' experiences.

AIMS AND OBJECTIVE: To explore patients' experiences of acute dyspnoea, physical functioning and perspectives on course of illness prior to admission to the emergency department. BACKGROUND: Many emergency admissions are considered unnecessary and avoidable. In this perspective, it seems relevant to gain insight into the patients' perspective on acute dyspnoea and the need for emergency admission. However, only few studies have investigated reasons for emergency admission from a patient perspective. DESIGN: A qualitative study was conducted with semi-structured interviews among six patients previously admitted to the emergency department due to dyspnoea. Data collection and analysis were carried out according to Kvale & Brinkmann using meaning condensation. FINDINGS: Dyspnoea was experienced as an unpleasant breathlessness in the form of pain or suffocation, which limited usual physical activities, negatively impacting on quality of life. Self-management strategies such as medication, breathing exercises, distraction from breathing, and mental and physical relaxation in general were used to avoid hospital admission. The chronically ill patients saw the following ways to alternate course of disease to avoid admissions to the emergency department: easier access to specialised emergency medical care, medical supplies in the patient's home and making existing physical exercise programmes more accessible and interesting. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: It would be relevant to further investigate whether prehospital interventions may remedy acute dyspnoea among chronically ill patients, and whether such interventions are cost-effective.

Risk of suicide following an alcohol-related emergency hospital admission: An electronic cohort study of 2.8 million people.

OBJECTIVE: Alcohol misuse is a well-known risk factor for suicide however, the relationship between alcohol-related hospital admission and subsequent risk of death from suicide is unknown. We aimed to determine the risk of death from suicide following emergency admission to hospital with an alcohol-related cause. METHODS: We established an electronic cohort study of all 2,803,457 residents of Wales, UK, aged from 10 to under 100 years on 1 January 2006 with six years' follow-up. The outcome event was death from suicide defined as intentional self-harm (ICD-10 X60-84) or undetermined intent (Y10-34). The main exposure was an alcohol-related admission defined as a 'wholly attributable' ICD-10 alcohol code in the admission record. Admissions were coded for the presence or absence of co-existing psychiatric morbidity. The analysis was by Cox regression with adjustments for confounding variables within the dataset. RESULTS: During the study follow-up period, there were 15,546,355 person years at risk with 28,425 alcohol-related emergency admissions and 1562 suicides. 125 suicides followed an admission (144.6 per 100,000 person years), of which 11 (9%) occurred within 4 weeks of discharge. The overall adjusted hazard ratio (HR) for suicide following admission was 26.8 (95% confidence interval (CI) 18.8 to 38.3), in men HR 9.83 (95% CI 7.91 to 12.2) and women HR 28.5 (95% CI 19.9 to 41.0). The risk of suicide remained substantial in subjects without known co-existing psychiatric morbidity: HR men 8.11 (95% CI 6.30 to 10.4) and women HR 24.0 (95% CI 15.5 to 37.3). The analysis was limited by the absence in datasets of potentially important confounding variables and the lack of information on alcohol-related harm and psychiatric morbidity in subjects not admitted to hospital. CONCLUSION: Emergency alcohol-related hospital admission is associated with an increased risk of suicide. Identifying individuals in hospital provides an opportunity for psychosocial assessment and suicide prevention of a targeted at-risk group before their discharge to the community.

Human Factors and Simulation in Emergency Medicine.

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Pain management of acute limb trauma patients with intravenous lidocaine in emergency department.

INTRODUCTION: This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. METHODS: This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. RESULTS: Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49). CONCLUSION: The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.