Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study.

Background: Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity. Objectives: Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein. Methods: This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search. Discussion: This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

BACKGROUND: People admitted to hospital with symptoms of breathlessness are often severely ill and need quick, accurate assessment to facilitate timely initiation of appropriate treatments. In low resource settings, such as Malawi, limited access to diagnostic equipment impedes patient assessment. Failure to identify and treat the underlying diagnosis may lead to preventable death. AIMS: This cohort study aims to delineate between common, treatable causes of breathlessness among adult patients admitted to hospital in Malawi and measure survival. We will also evaluate the performance of blood markers to diagnose and differentiate between conditions. The results will help us develop context-appropriate diagnostic and treatment algorithms based on resources available in the health system Methods in brief: We will recruit adult patients who present to hospital with breathlessness in a central national referral hospital (Queen Elizabeth Central Hospital, Blantyre), and a district hospital (Chiradzulu District Hospital, Chiradzulu). We will conduct enhanced diagnostic tests to determine causes of breathlessness against internationally accepted diagnostic guidelines. Patients will be followed up throughout their hospital admission and after discharge, until 90 days. INTERPRETATION: This study aligns with World Health Assembly resolutions on 'Strengthening diagnostics capacity' and on 'Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies'. The results of this study will have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve care and outcomes for acutely unwell patients.

Factors associated with correction of personal protective equipment nonadherence in a multidisciplinary emergency department setting: A retrospective video review.

BACKGROUND: Despite local and national recommendations, health care provider adherence to personal protective equipment (PPE) varied during the COVID-19 pandemic. Previous studies have identified factors influencing initial PPE adherence but did not address factors influencing behaviors leading to correction after initial nonadherence. METHODS: We conducted a retrospective video review of 18 pediatric resuscitations involving aerosol-generating procedures from March 2020 to December 2022 to identify factors associated with nonadherence correction. We quantified adherent and nonadherent providers, instances of PPE nonadherence, and time to correction. We also analyzed correction behaviors, including provider actions and correction locations. RESULTS: Among 434 providers, 362 (83%) were nonadherent with at least 1 PPE. Only 186 of 1,832 instances of nonadherence were corrected, primarily upon room entry and during patient care. Correction time varied by PPE type and nonadherence level (incomplete vs absent). Most corrections were self-initiated, with few reminders from other providers. DISCUSSION: Potential barriers to correction include a lack of social pressure and external reminders. Solutions include optimizing PPE availability, providing real-time feedback, and educating on double gloving. CONCLUSIONS: Most providers were nonadherent to PPE requirements during high-risk infection transmission events. The low correction rate suggests challenges in promoting collective responsibility and maintaining protective behaviors during medical emergencies.

Building a performance measurement framework for telephone triage services in Finland: a consensus-making study based on nominal group technique.

BACKGROUND: There has been a significant expansion in the measurement of healthcare system performance. However, there is a lack of a comprehensive performance measurement framework to assess the effects of telephone triage services on the urgent care system. The aim of our Delphi study was to construct and validate a performance measurement framework designed explicitly for telephone triage services. METHODS: This study was conducted in Finland with a group of eight experienced senior physicians from the country's 20 largest joint emergency departments, serving over 90% of the population for urgent care. The Nominal Group Technique (NGT) was utilised to achieve consensus on measuring telephone triage performance. Initially, performance indicators (PIs) were identified through Delphi method rounds from December 10th to December 27th, 2021, with eight experts participating, and from December 29th, 2021, to January 23rd, 2022, where five of these experts responded. NGT further deepened these themes and perspectives, aiding in the development of a comprehensive performance measurement framework. The final framework validation began with an initial round from February 13th to March 3rd, 2022, receiving five responses. Due to the limited number of responses, an additional validation round was conducted from October 29th to November 7th, 2023, resulting in two more responses, increasing the total number of respondents in the validation phase to seven. RESULTS: The study identified a strong desire among professionals to implement a uniform framework for measuring telephone triage performance. The finalised framework evaluates telephone triage across five dimensions: service accessibility, patient experience, quality and safety, process outcome, and cost per case. Eight specific PIs were established, including call response metrics, service utility, follow-up care type and distribution, ICPC-2 classified encounter reasons, patient compliance with follow-up care, medical history review during assessment, and service cost per call. CONCLUSIONS: This study validated a performance measurement framework for telephone triage services, utilising existing literature and the NGT method. The framework includes five key dimensions: patient experience, quality and safety, outcome of the telephone triage process, cost per case, and eight PIs. It offers a structured and comprehensive approach to measuring the overall performance of telephone triage services, enhancing our ability to evaluate these services effectively.

Perceived autonomy support in individuals with Parkinson's disease requiring emergency care: a cross-sectional pilot study.

BACKGROUND: Individuals with Parkinson's disease (PD) report a diminished perceived functional autonomy as their condition progresses. For those seeking emergency care, it is unknown whether the patient-physician relationship is instrumental in respecting patient autonomy. This study evaluated patient autonomy ideals in individuals with PD requiring emergency care and the perceived support for autonomy from emergency department physicians. METHOD: Individuals with PD (n = 36, average age 78.1 years) were surveyed using the Ideal Patient Autonomy questionnaire (IPA) and the Health Care Climate Questionnaire (HCCQ). A multivariable regression analysis assessed whether patients' Hoehn and Yahr stage and IPA questionnaire results predicted HCCQ items. RESULTS: The IPA questionnaire revealed that individuals with PD in need of emergency care emphasize the significance of medical expertise (IPA 'doctor should decide' theme 0.71) in decision-making and their desire to be fully informed about all potential risks (IPA 'obligatory risk information' theme 0.71). The average HCCQ values showed a decreasing trend across Hoehn and Yahr stages 1 to 5: 6.19, 6.03, 5.83, 5.80, and 5.23, respectively. HY scale values also influenced HCCQ items related to the physician's role. CONCLUSION: In our cohort, individuals with Parkinson's disease tend to rely on medical expertise for decision-making and prioritize complete risk information during emergency care. However, this autonomy support diminishes as functional disability levels increase.

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre.

BACKGROUND: Prehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome. METHODS: We conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality. RESULTS: Ninety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37-63], median total burned surface area 36% [IQR 25-51] and median body mass index 26.56 kg/m2 [IQR 22.86-30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32-0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27-9.66), inhalation injury (OR 3.57, 95% CI: 1.36-9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57-16.84) and prehospital intubation (5.38, 95% CI: 1.92-15.92). CONCLUSION: We showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation. TRIAL REGISTRATION: German Clinical Trial Registry (ID: DRKS00033516).

An emergency department transitional care team prevents unnecessary hospitalization of older adults: a mixed methods study.

INTRODUCTION: Older adults with acute functional decline may visit emergency departments (EDs) for medical support despite a lack of strict medical urgency. The introduction of transitional care teams (TCT) at the ED has shown promise in reducing avoidable admittances. However, the optimal composition and implementation of TCTs are still poorly defined. We evaluated the effect of TCTs consisting of an elderly care physician (ECP) and transfer nurse versus a transfer nurse only on reducing hospital admissions, as well as the experience of patients and caregivers regarding quality of care. METHODS: We assessed older adults (≥ 65 years) at the ED with acute functional decline but no medical indication for admission. Data were collected on type and post-ED care, and re-visits were evaluated over a 30-day follow-up period. Semi-structured interviews with stakeholders were based on the Consolidated-Framework-for-Implementation-Research, while patient and caregiver experiences were collected through open-ended interviews. RESULTS: Among older adults (N = 821) evaluated by the TCT, ECP and transfer nurse prevented unnecessary hospitalization at the same rate (81.2%) versus a transfer nurse alone (79.5%). ED re-visits were 15.6% (ECP and transfer nurse) versus 13.5%. The interviews highlighted the added value of an ECP, which consisted of better staff awareness, knowledge transfer and networking with external organizations. The TCT intervention in general was broadly supported, but adaptability was regarded as an important prerequisite. CONCLUSION: Regardless of composition, a TCT can prevent unnecessary hospitalization of older adults without increasing ED re-visiting rates, while the addition of an ECP has a favourable impact on patient and professional experiences.

Health care utilization of patients with acute abdominal pain before and after emergency department visits.

BACKGROUND: Acute abdominal pain (AAP) is a major driver for capacity-use in emergency departments (EDs) worldwide. Yet, the health care utilization of patients with AAP before and after the ED remains unclear. The primary objective of this study was to describe adult patients presenting to the ED with AAP and their outpatient care (OC) use before and after the ED. Secondary objectives included description of hospitalization rates, in-hospital mortality, ED re-visits, and exploration of potential risk factors for hospitalization and ED re-visits. METHODS: For the analysis, we combined routine hospital data from patients who visited 15 EDs in Germany in 2016 with their statutory health insurance OC claims data from 2014 to 2017. Adult patients were included based on a chief complaint or an ED diagnosis indicating unspecific AAP or the Manchester Triage System indicator "Abdominal pain in adults". Baseline characteristics, ED diagnosis, frequency and reason of hospitalization, frequency and type of prior-OC (prOC) use up to 3 days before and of post-OC use up to 30 days after the ED visit. MAIN RESULTS: We identified 28,085 adults aged ≥ 20 years with AAP. 39.8% were hospitalized, 33.9% sought prOC before the ED visit (48.6% of them were hospitalized) and 62.7% sought post-OC up to 30 days after the ED visit. Hospitalization was significantly more likely for elderly patients (aged 65 and above vs. younger; adjusted OR 3.05 [95% CI 2.87; 3.25]), prOC users (1.71 [1.61; 1.90]) and men (1.44 [1.37; 1.52]). In-hospital mortality rate was 3.1% overall. Re-visiting the ED within 30 days was more likely for elderly patients (1.32 [1.13; 1.55) and less likely for those with prOC use (0.37 [0.31; 0.44]). CONCLUSIONS: prOC use was associated with more frequent hospitalizations but fewer ED re-visits. ED visits by prOC patients without subsequent hospitalization may indicate difficulties of OC resources to meet the complex diagnostic requirements and expectations of this patient population. Fewer ED re-visits in prOC users indicate effective care in this subgroup.

Healthcare staff experiences on the impact of COVID-19 on emergency departments: a qualitative study.

BACKGROUND: The COVID-19 pandemic has had a major impact on the access and delivery of healthcare services, posing unprecedented challenges to healthcare staff worldwide. Frontline healthcare staff faced unique stressors and challenges that impact their well-being and patient care. This qualitative study aimed to explore the experiences and perspectives of frontline ED healthcare staff on emergency care services during the COVID-19 pandemic, providing valuable insights into the challenges, adaptations, and lessons learned in delivering emergency care. METHODS: This study utilized a qualitative approach. In-depth semi-structured interviews were conducted with 30 ED healthcare staff from three different hospitals located in Turkey between 15/03/2022 and 30/04/2022. Convenience sampling was used to recruit participants. The duration of the interviews ranged from 28 to 37 min. Data saturation was reached as no new information was gathered. The data were analyzed using the thematic analysis method. NVivo software was used to manage the data analysis process. Member check was carried out to ensure that the generated themes conformed to the participants' views. RESULTS: 15 sub-themes under three themes emerged: (1) the impact of COVID-19 on emergency care services, including sub-themes of "introducing a COVID-19 unit in the ED", "changes in the routine functioning of EDs", "changes in the number of ED visits", "quality of care", "resources", and "increased workload"; (2) the psychological effects of COVID-19 on ED healthcare staff, including sub-themes of "staying away from family", "fear", "society's perspective on healthcare professionals", "morale-staff burnout", "psychological and emotional effects", and "unable to receive sufficient support"; and (3) the difficulties faced by ED healthcare staff, including sub-themes of "difficult working conditions", "community-based effects difficulties", and "COVID-19 is an unknown situation". CONCLUSION: Staff burnout threatens the quality of patient care and staff retention, and therefore this should be addressed by ED directors and leaders. This study could inform appropriate stakeholders regarding lessons learned from COVID-19 to better manage future pandemics. Learning from such lived experiences and developing appropriate interventions to minimize the difficulties faced during COVID-19 would allow better management of future pandemics. This study calls for a reform to address the challenges faced by healthcare staff, improve the overall response to public health crises, and enhance the resilience of healthcare systems for future crises.

Crisis Receiving and Stabilization Facilities: Designing Systems for High-Acuity Populations.

Crisis facilities provide a safe and therapeutic alternative to emergency departments and jails for people experiencing behavioral health emergencies. Program design should center around customer needs which include individuals and families in crisis and key community stakeholders like first responders. Ideally, a crisis system should be organized into a broad continuum of services that ensures care is provided in the least restrictive setting, even for people with high acuity needs, and stakeholders should have a clear understanding of the capabilities of each component facility and the population it can safely serve. This paper provides a framework to help policymakers achieve this goal.

Performance of blood enterovirus and parechovirus polymerase chain reaction testing in young febrile infants: a prospective multicentre observational study.

OBJECTIVES: To analyse the performance of blood enterovirus and parechovirus PCR testing (ev-PCR) for invasive bacterial infection (IBI) (isolation of a single bacterial pathogen in a blood or cerebrospinal fluid culture) when evaluating well-appearing infants ≤90 days of age with fever without a source (FWS). METHODS: We describe the well-appearing infants ≤90 days of age with FWS and normal urine dipstick. We performed a prospective, observational multicentre study at five paediatric emergency departments between October 2020 and September 2023. RESULTS: A total of 656 infants were included, 22 (3.4%) of whom were diagnosed with an IBI (bacteraemia in all of them and associated with meningitis in four). The blood ev-PCR test was positive in 145 (22.1%) infants. One patient with positive blood ev-PCR was diagnosed with an IBI, accounting for 0.7% (95% CI 0.02 to 3.8) compared with 4.1% (95% CI 2.6 to 6.2) in those with a negative test (p=0.04). All four patients with bacterial meningitis had a negative blood ev-PCR result. Infants with a positive blood ev-PCR had a shorter hospital stay (median 3 days, IQR 2-4) compared with 4 days (IQR 2-6) for those with negative blood ev-PCR (p=0.02), as well as shorter duration of antibiotic treatment (median 2 days, IQR 0-4 vs 2.5 days, IQR 0-7, p=0.01). CONCLUSIONS: Young febrile infants with a positive blood ev-PCR are at a low risk of having an IBI. Incorporating the blood ev-PCR test into clinical decision-making may help to reduce the duration of antibiotic treatments and length of hospital stay.

Emergency nurses' experiences of caring for brought-in-dead persons and their relatives-a qualitative study.

AIM: To explore how emergency nurses experienced caring for brought-in-dead persons and their relatives, and what hindered or facilitated this care in an emergency setting. DESIGN: A qualitative study using Interpretive Description. METHODS: Data were collected as individual interviews with 13 nurses at seven Danish emergency departments from February to June 2023. FINDINGS: Our analysis revealed the overarching theme 'Navigating the complexities of providing holistic care in a constrained environment', covering five sub-themes: (1) An important yet not recognized nursing task; (2) Pending care needs of the living and the dead; (3) No physical or mental room for the brought-in-dead persons; (4) Utilizing personal experiences in the absence of formal education and training and (5) Navigating professionalism and empathy. CONCLUSION: Emergency departments posed unique challenges in providing care to brought-in-dead persons and their relatives. IMPLICATIONS FOR THE PROFESSION: The unrecognized nature of caring for brought-in-dead persons and their relatives suggests a universal undervaluation of this care in emergency departments. IMPACT: Care for brought-in-dead persons and their relatives is neither recognized nor evidence-based. This study initiates a discussion of the circumstances for delivering care for persons brought-in-dead and has an impact on nurses and nursing leaders employed in emergency departments. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: None.

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study

Abstract Objective: To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students. Methods: 33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge'sg. Results: Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20). Conclusion: HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

An After-Hours Telemedicine Urgent Care Service May Not Improve Access to Care for Underserved Populations.

Background: After-hours telemedicine services for emergency care are thought to offer a solution for patients who live at a distance from traditional face-to-face emergency services. This study evaluates such a service in a Health Maintenance Organization, focusing on the differences between central and peripheral populations. Methods: In this cross-sectional database study, we collected data regarding the encounter and patient characteristics, including prescriptions, referrals for further evaluation in a traditional emergency department (ED), and the distance from a traditional ED. Other outcome measures included health care utilization after the encounter such as primary care physician (PCP) encounters, additional telemedicine encounters, ED visits, and hospitalization. Results: In total, 45,411 patient visits were analyzed. Medication was prescribed in 25% of the encounters, and a referral to an ED was given in 22%. In total, 17.7% of the patients visited an ED within 24 h of the index encounter. In total, 64.8% of patients visited a PCP in the following 30 days. No further care was needed in 32.4% of the encounters. In multivariable logistic regression, the odds of using the service were lower for low socio-economic status groups and inhabitants of the periphery than the central areas. A weak reverse correlation was observed in Jewish sectors regarding distance from traditional ED, whereas no correlation was found in the Arab sector. Conclusion: It is commonly believed that telemedicine overcomes geographical barriers. The results of this research do not support this hypothesis.

Differences in code status practice patterns among emergency clinicians working in Japan and the United States.

OBJECTIVE: This study aimed to examine self-reported code-status practice patterns among emergency clinicians from Japan and the U.S. METHODS: A cross-sectional questionnaire was distributed to emergency clinicians from one academic medical center and four general hospitals in Japan and two academic medical centers in the U.S. The questionnaire was based on a hypothetical case involving a critically ill patient with end-stage lung cancer. The questionnaire items assessed whether respondent clinicians would be likely to pose questions to patients about their preferences for medical procedures and their values and goals. RESULTS: A total of 176 emergency clinicians from Japan and the U.S participated. After adjusting for participants' backgrounds, emergency clinicians in Japan were less likely to pose procedure-based questions than those in the U.S. Conversely, emergency clinicians in Japan showed a statistically higher likelihood of asking 10 out of 12 value-based questions. CONCLUSION: Significant differences were found between emergency clinicians in Japan and the U.S. in their reported practices on posing procedure-based and patient value-based questions. PRACTICE IMPLICATIONS: Serious illness communication training based in the U.S. must be adapted to the Japanese context, considering the cultural characteristics and practical responsibilities of Japanese emergency clinicians.

Health care workers' experiences of calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya.

BACKGROUND: When caring for critically ill patients, health workers often need to 'call-for-help' to get assistance from colleagues in the hospital. Systems are required to facilitate calling-for-help and enable the timely provision of care for critically ill patients. Evidence around calling-for-help systems is mostly from high income countries and the state of calling-for-help in hospitals in Tanzania and Kenya has not been formally studied. This study aims to describe health workers' experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. METHODS: Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The interviews were transcribed, translated and the data thematically analyzed. RESULTS: The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: 1) Calling-for-help structures: there is lack of functioning structures for calling-for-help; 2) Calling-for-help processes: the calling-for-help processes are innovative and improvised; and 3) Calling-for-help outcomes: the help that is provided is not as requested. CONCLUSION: Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges likely cause delays and decrease the quality of care, potentially resulting in unnecessary mortality and morbidity.

Violence in the emergency department: a quantitative survey study of healthcare providers in India.

BACKGROUND: Workplace violence (WPV) in Emergency Departments (EDs) is an increasingly recognized challenge healthcare providers face in low-resource settings. While studies have highlighted the increased prevalence of WPV in healthcare, most of the existing research has been conducted in developed countries with established laws and repercussions for violence against healthcare providers. More data on WPV against ED providers practicing in low-resource settings is necessary to understand these providers' unique challenges. OBJECTIVE: This study aims to gain insight into the incidence and characteristics of WPV among ED healthcare providers in India. METHODS: This study was conducted at two EDs in geographically distinct regions of India. A survey was designed to assess violence in EDs among healthcare providers. Surveys were distributed to ED workplace providers, completed by hand, and returned anonymously. Data was entered and stored in the RedCAP database to facilitate analysis. RESULTS: Two hundred surveys were completed by physicians, nurses, and paramedics in Indian EDs. Most reported events involved verbal abuse (68%), followed by physical abuse (26%), outside confrontation (17%), and stalking (5%). By far, the most common perpetrators of violence against healthcare workers were bystanders including patient family members or other accompanying individuals. Notably, reporting was limited, with most cases conveyed to ED or hospital administration. CONCLUSION: These results underscore the prevalence of WPV among Indian ED healthcare providers. High rates of verbal abuse followed by physical abuse are of concern. Most perpetrators of WPV against healthcare providers in this study were patient family members or bystanders rather than the patients themselves. It is imperative to prioritize implementing prevention strategies to create safer work environments for healthcare workers.

Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population.

BACKGROUND: Ethnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder. METHODS: A descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal-Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures. RESULTS: Of 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3-7), whereas those from mixed ethnic groups had the lowest (2, IQR 0-6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74-0.87; Black: 0.67, 95% CI 0.58-0.79; mixed: 0.71, 95% CI 0.59-0.86; other: 0.79, 95% CI 0.67-0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60-0.67; Black: 0.60, 95% CI 0.54-0.68; mixed: 0.60, 95% CI 0.51-0.71; other: 0.61, 95% CI 0.54-0.69; p < 0.0001 for all). CONCLUSIONS: Significant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.

Healthcare delivery to patients from culturally and linguistically diverse backgrounds in emergency care: a scoping review protocol.

BACKGROUND: Worldwide, the culturally and linguistically diverse (CALD) population is increasing, and is predicted to reach 405 million by 2050. The delivery of emergency care for the CALD population can be complex due to cultural, social, and language factors. The extent to which cultural, social, and contextual factors influence care delivery to patients from CALD backgrounds throughout their emergency care journey is unclear. Using a systematic approach, this review aims to map the existing evidence regarding emergency healthcare delivery for patients from CALD backgrounds and uses a social ecological framework to provide a broader perspective on cultural, social, and contextual influence on emergency care delivery. METHODS: The Joanna Briggs Institute (JBI) scoping review methodology will be used to guide this review. The population is patients from CALD backgrounds who received care and emergency care clinicians who provided direct care. The concept is healthcare delivery to patients from CALD backgrounds. The context is emergency care. This review will include quantitative, qualitative, and mixed-methods studies published in English from January 1, 2012, onwards. Searches will be conducted in the databases of CINAHL (EBSCO), MEDLINE (Ovid), Embase (Elsevier), SocINDEX (EBSCO), Scopus (Elsevier), and a web search of Google Scholar. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram will be used to present the search decision process. All included articles will be appraised using the Mixed Methods Appraisal Tool (MMAT). Data will be presented in tabular form and accompanied by a narrative synthesis of the literature. DISCUSSION: Despite the increased use of emergency care service by patients from CALD backgrounds, there has been no comprehensive review of healthcare delivery to patients from CALD backgrounds in the emergency care context (ED and prehospital settings) that includes consideration of cultural, social, and contextual influences. The results of this scoping review may be used to inform future research and strategies that aim to enhance care delivery and experiences for people from CALD backgrounds who require emergency care. SYSTEMATIC REVIEW REGISTRATION: This scoping review has been registered in the Open Science Framework https://doi.org/10.17605/OSF.IO/HTMKQ.

Crisis-ready educational skills of life support in newborns and adults' scenarios: the impact of simulation-based training on student proficiency.

OBJECTIVE: Aim: To assess the impact of multidisciplinary simulation training on the educational outcomes of medical students in the emergency care of adults and newborns and implement changes in the curriculum to master simulation scenarios more. PATIENTS AND METHODS: Materials and Methods: To assess the differences in learning outcomes between medical students who study the same curriculum without simulation interventions and those who undergo multidisciplinary emergency care simulation training. A quasi-experimental approach was used to assign students to the Intervention Group or the Control Group. RESULTS: Results: According to individual criteria, the lowest scores in both groups were obtained for the stages that required the greatest accuracy and correct technique. After the appropriate cycle of initiation, the results in both groups improved significantly, but the results of students from the first group were significantly higher than those of students from the second group. Despite the absence of a significant difference in the average overall score for the skills, students in the first group significantly improved the accuracy and correctness of the criteria that assess the technical aspects of performance, while students in the second group mainly improved the quality of the descriptive and communicative parts of the practical skill. CONCLUSION: Conclusions: We believe that reallocating curricular time to additional hours dedicated to simulation scenarios will better prepare aspiring healthcare professionals for the demanding and dynamic nature of their career, as we continue to increase our understanding of the potential of simulation-based education.

Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis.

BACKGROUND: Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS. METHODS: A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated. RESULTS: Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity. CONCLUSION: 3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.