Relapsing polychondritis.

This is a case report of a 67-year-old man with the rare autoimmune disease relapsing polychondritis. The patient was initially diagnosed by general practitioners with erysipelas around his left ear, which was found red, swollen, and painful. Due to the lack of effect from antibiotics, the patient was referred to an emergency department. A rheumatologist recognised the patterns of the rare disease, diagnosed the patient and initiated proper treatment. The case clarifies the difficulty in diagnosing relapsing polychondritis, mainly due to the rarity and lack of knowledge of the disease.

Comparison of Acute Versus Subacute Coronary Angiography in Patients With NON-ST-Elevation Myocardial Infarction (from the NONSTEMI Trial).

The optimal timing of coronary angiography (CAG) in high-risk patients with acute coronary syndrome without persisting ST-segment elevation (NST-ACS) remains undetermined. The NON-ST-Elevation Myocardial Infarction trial aimed to compare outcomes in NSTE-ACS patients randomized to acute CAG (STEMI-like approach) with patients randomized to medical therapy and subacute CAG. We randomized 496 patients with suspected NST-ACS based on symptoms and significant regional ST depressions and/or elevated point-of-care troponin T (POC-cTnT) (≥50 ng/l) to either acute CAG (<2 hours, n = 245) or subacute CAG (<72 hours, n = 251). The primary end point was a composite of all-cause death, reinfarction, and readmission with congestive heart failure within 1 year from randomization. A final acute coronary syndrome (ACS) diagnosis was assigned to 429 (86.5%) patients. The median time from randomization to revascularization was 1.3 hours in the acute CAG group versus 51.1 hours in the subacute CAG group (p <0.001). The composite end point occurred in 25 patients (10.2%) in the acute CAG group and 29 (11.6%) in the subacute CAG group, p = 0.62. The acute CAG group had a 1-year all-cause mortality of 5.7% compared with 5.6% in the subacute CAG group, p = 0.96. In conclusion, neither the composite end point of all-cause death, reinfarction, and readmission with congestive heart failure nor mortality differed between an acute and subacute CAG approach in NSTE-ACS patients. However, identification of NSTE-ACS patients in the prehospital phase and direct triage to an invasive center is feasible, safe and may facilitate early diagnosis and revascularization.

"Hand hygiene perception and self-reported hand hygiene compliance among emergency medical service providers: a Danish survey".

BACKGROUND: Hand hygiene (HH), a cornerstone in infection prevention and control, lacks quality in emergency medical services (EMS). HH improvement includes both individual and institutional aspects, but little is known about EMS providers' HH perception and motivations related to HH quality. Therefore, we aimed to investigate the HH perception and assess potential factors related to self-reported HH compliance among the EMS cohort. METHODS: A cross-sectional, self-administered questionnaire consisting of 24 items (developed from the WHOs Perception Survey for Health-Care Workers) provided information on demographics, HH perceptions and self-reported HH compliance among EMS providers from Denmark. RESULTS: Overall, 457 questionnaires were answered (response rate 52%). Most respondents were advanced-care providers, males, had > 5 years of experience, and had received HH training < 3 years ago. HH was perceived a daily routine, and the majority rated their HH compliance rate ≥ 80%. Both infection severity and the preventive effect of HH were acknowledged. HH quality was perceived important to colleagues and patients, but not as much to managers. Access to supplies, simple instructions and having or being "a good example" were perceived most effective to improve HH compliance. Self-reported HH compliance was associated with years of experience and perceptions of HCAI's impact on patient outcome, HH's preventive effect, organizational priority, HH's importance to colleagues and patients, and the effort HH requires (p ≤ 0.05). CONCLUSION: Danish EMS providers acknowledged the impact of infections and the preventive effect of HH, and perceived access to HH supplies at the point of care, having or being "a good example" and simple instructions effective to improve HH compliance. Moreover, several behavioral-, normative- and control beliefs were associated with self-reported HH compliance, and thus future improvement strategies should be multimodal.

Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols.

BACKGROUND: Prehospital acute pain is a frequent symptom that is often inadequately managed. The concerns of opioid induced side effects are well-founded. To ensure patient safety, ambulance personnel are therefore provided with treatment protocols with dosing restrictions, however, with the concomitant risk of insufficient pain treatment of the patients. The aim of this study was to investigate the impact of a liberal intravenous fentanyl treatment protocol on efficacy and safety measures. METHODS: A two-armed, cluster-randomised trial was conducted in the Central Denmark Region over a 1-year period. Ambulance stations (stratified according to size) were randomised to follow either a liberal treatment protocol (3 µg/kg) or a standard treatment protocol (2 µg/kg). The primary outcome was the proportion of patients with sufficient pan relief (numeric rating scale (NRS, 0-10) < 3) at hospital arrival. Secondary outcomes included abnormal vital parameters as proxy measures of safety. A multi-level mixed effect logistic regression model was applied. RESULTS: In total, 5278 patients were included. Ambulance personnel following the liberal protocol administered higher doses of fentanyl [117.7 µg (95% CI 116.7-118.6)] than ambulance personnel following the standard protocol [111.5 µg (95% CI 110.7-112.4), P = 0.0001]. The number of patient with sufficient pain relief at hospital arrival was higher in the liberal treatment group than the standard treatment group [44.0% (95% CI 41.8-46.1) vs. 37.4% (95% CI 35.2-39.6), adjusted odds ratio 1.47 (95% CI 1.17-1.84)]. The relative decrease in NRS scores during transport was less evident [adjusted odds ratio 1.18 (95% CI 0.95-1.48)]. The occurrences of abnormal vital parameters were similar in both groups. CONCLUSIONS: Liberalising an intravenous fentanyl treatment protocol applied by ambulance personnel slightly increased the number of patients with sufficient pain relief at hospital arrival without compromising patient safety. Future efforts of training ambulance personnel are needed to further improve protocol adherence and quality of treatment. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02914678 ). Date of registration: 26th September, 2016.

Compliance with hand hygiene in emergency medical services: an international observational study.

INTRODUCTION: Healthcare-associated infection caused by insufficient hygiene is associated with mortality, economic burden, and suffering for the patient. Emergency medical service (EMS) providers encounter many patients in different surroundings and are thus at risk of posing a source of microbial transmission. Hand hygiene (HH), a proven infection control intervention, has rarely been studied in the EMS. METHODS: A multicentre prospective observational study was conducted from December 2016 to May 2017 in ambulance services from Finland, Sweden, Australia and Denmark. Two observers recorded the following parameters: HH compliance according to WHO guidelines (before patient contact, before clean/aseptic procedures, after risk of body fluids, after patient contact and after contact with patient surroundings). Glove use and basic parameters such as nails, hair and use of jewellery were also recorded. RESULTS: Sixty hours of observation occurred in each country, for a total of 87 patient encounters. In total, there were 1344 indications for HH. Use of hand rub or hand wash was observed: before patient contact, 3%; before clean/aseptic procedures, 2%; after the risk of body fluids, 8%; after patient contact, 29%; and after contact with patient-related surroundings, 38%. Gloves were worn in 54% of all HH indications. Adherence to short or up done hair, short, clean nails without polish and no jewellery was 99%, 84% and 62%, respectively. HH compliance was associated with wearing gloves (OR 45; 95% CI 10.8 to 187.8; p=0.000) and provider level (OR 1.7; 95% CI 1.1 to 2.4; p=0.007), but not associated with gender (OR 1.3; 95% CI 0.9 to 1.9; p=0.107). CONCLUSION: HH compliance among EMS providers was remarkably low, with higher compliance after patient contacts compared with before patient contacts, and an over-reliance on gloves. We recommend further research on contextual challenges and hygiene perceptions among EMS providers to clarify future improvement strategies.

Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction.

OBJECTIVE: The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction. METHODS AND RESULTS: All prehospital emergency medical service vehicles in the Central Denmark Region were equipped with a point-of-care cardiac troponin T device (Roche Cobas h232) for routine use in all patients with a suspected acute myocardial infarction. During the study period, 1 June 2012-30 November 2015, prehospital point-of-care cardiac troponin T measurements were performed in a total of 19,615 cases seen by the emergency medical service and 18,712 point-of-care cardiac troponin T measurements in 15,781 individuals were matched with an admission. A final diagnosis of acute myocardial infarction was confirmed in 2187 cases and a total of 2150 point-of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those with values <50 ng/l, log-rank: p<0.001. The following variables showed the strongest association with mortality in multivariable analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90-2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1.74-2.14), diabetes mellitus (hazard ratio 1.42, 95% confidence interval: 1.27-1.59) and age, one-year increase (hazard ratio 1.08, 95% confidence interval: 1.08-1.09). CONCLUSIONS: Patients with suspected acute myocardial infarction and a prehospital point-of-care cardiac troponin T ≥50 ng/l have a poor prognosis irrespective of the final diagnosis. Routine troponin measurement in the prehospital setting has a high predictive value and can be used to identify high-risk patients even before hospital arrival so that they may be re-routed directly for advanced care at an invasive centre.

Do prehospital providers and emergency nurses agree on triage assignment?: an efficacy study.

OBJECTIVES: The aim of this study was to investigate the agreement on triage level between prehospital providers and emergency department (ED) nurses in clinical practice when using the same triage system. The objectives were as follows: (a) What is the agreement of triage between prehospital providers and ED nurses, when using Danish Emergency Process Triage (DEPT) correctly? (b) Which part of the triage process yields the highest agreement regarding the final triage? METHODS: The study was a prospective and observational efficacy study. Patients transported to the ED by ambulances were included. They were triaged by prehospital providers while being transported by ambulance to the ED, and by ED nurses upon arrival. Triage was done using the DEPT - a five-level triage system based on vital signs and a presenting complaint algorithm. An agreement analysis was performed. RESULTS: DEPT was used correctly by both professions in 292 patients. In 182 (62%) patients the prehospital providers and the ED nurses agreed on the same triage level. This equals to κ=0.47 [95% confidence interval (CI): 0.41-0.56]. When considering the triage based on vital signs the agreement was 72% (κ=0.46; 95% CI: 0.41-0.47), and based on presenting complaint the agreement was 46% (κ=0.41; 95% CI: 0.37-0.44). CONCLUSION: There was a moderate interrater agreement on triage assignment between ED nurses and prehospital providers. They agreed on final triage more often if they agreed on triage based on vital signs rather than presenting complaints.

Prehospital infection control and prevention in Denmark: a cross-sectional study on guideline adherence and microbial contamination of surfaces.

BACKGROUND: Prehospital acute care and treatment have become more complex, and while invasive procedures are standard procedures, focus on infection control and prevention is scarce. We aimed to evaluate guideline adherence, microbial contamination, and associated risk factors. METHODS: In a nationwide cross-sectional study, we evaluated guideline adherence to thorough cleaning (TC) once a day, and moderate cleaning (MC) in-between patient courses. Microbial contamination on hand-touch sites (HTS) and provider-related sites (PRS) was assessed by total aerobic colony forming units (CFU) and presence of selected pathogens, using swab and agar imprints. Also, microbial contamination was assessed in relation to potential risk factors. RESULTS: 80 ambulances and emergency medical service (EMS) providers were enrolled. Adherence to guidelines regarding TC was 35%, but regarding MC it was 100%. In total, 129 (27%) of 480 HTS presented a total CFU > 2.5/cm2 and/or pathogenic growth, indicating hygiene failures. The prevalence of selected pathogens on HTS was: S. aureus 7%; Enterococcus 3% and Enterobacteriaceae 1%. Total CFU on the PRS ranged from 0 to 250/cm2, and the prevalence of pathogens was 18% (S. aureus 15%, Enterococcus 3% and Enterobacteriaceae 0.3%). Methicillin-resistant S. aureus was found in one sample, and Vancomycin-resistant Enterococcus in two. No Enterobacteriaceae with extended-spectrum beta-lactamases were recorded. CONCLUSION: Guideline adherence was suboptimal, and many HTS did not comply fully with proposed standards for cleanliness. Pathogens were demonstrated on both HTS and PRS, indicating that the EMS may be a source of infection in hospitalized patients. Moreover, cleaning effort and time appears associated with microbial contamination, but a comprehensive investigation of risk factors is needed.

POSAiDA: presence of Staphylococcus aureus/MRSA and Enterococcus/VRE in Danish ambulances. A cross-sectional study.

BACKGROUND: Every year approximately one out of ten Danish patients contracts a healthcare associated infection (HAI). Staphylococcus aureus and Enterococcus are prominent in the group of pathogenic bacteria that underlie HAIs, causing unnecessary inconvenience and prolonging hospitalization. Bacterial colonization often occurs due to indirect patient-to-patient transmission, caused by poor hygiene compliance. This study aims to determine the level of contamination with S. aureus/MRSA and Enterococcus/VRE on presumed clean blood pressure cuffs in the Danish ambulances. METHOD: Blood pressure cuffs were tested for contamination with S. aureus and Enterococcus when being cleaned according to everyday guidelines in this cross-sectional study. Imprints were performed with specific agar plates after cleaning with ethanol wipes. Positive imprints were typed and antibiotic susceptibility was determined. RESULTS: Both S. aureus and Enterococcus were found on blood pressure cuffs thought to be clean, however, to a limited extent. The average level of contamination by S. aureus was 0.54 CFU per 25 cm(2) (SD 1.98). Minimum and maximum values ranged from 0 to 12 CFU per 25 cm(2) and 10% of the 50 samples were positive. The average level of contamination by Enterococcus was 0.06 CFU per 25 cm(2) (SD 0.42). Minimum and maximum values ranged from 0 to 3 CFU per 25 cm(2) and 2% of the 50 samples were positive. All S. aureus isolates were found to be methicillin susceptible S. aureus (MSSA) and the one Enterococcus isolate was identified as Enterococcus faecalis, negative for vancomycin resistance genes. CONCLUSION: Staphylococcus aureus and Enterococcus were detectable on equipment thought to be clean. However, all detected bacteria showed susceptibility towards methicillin or vancomycin. Findings of pathogens after cleaning may be due to cross-contamination, improper cleaning and limited effect of the currently used cleaning procedure and are thought to affect the risk of infection. Therefore, we recommend a thorough evaluation of current cleaning procedures as well as increased focus on and further research into hygiene challenges in a prehospital setting. Future studies should be performed in order to demonstrate the level of bacterial contamination in all areas of the medical service, e.g., the ambulance environment, medical equipment, staff uniform and hand hygiene. Furthermore, in order to establish evidence for different cleaning procedures in situ we recommend testing the effect of different cleaning interventions by interventional designs.

UniStatus - a cross-sectional study on the contamination of uniforms in the Danish ambulance service.

BACKGROUND: Patients are at risk of contracting infections due to the presence of disease-causing microorganisms that can be transmitted from the medical staff's uniforms to the patient. The dual purpose of this study was to examine the contamination level of the uniforms worn by ambulance staff after a shift and to test the effect of washing of the uniform with and without a detergent containing acetic peroxide. METHODS: This was a cross-sectional study in which 30 ambulance staff uniforms were randomly selected for inclusion and divided into two groups. Before washing, 90 prints were performed with specific agar plates to determine bacterial contamination and to establish the prevalence of a variety of microorganisms. Group A uniforms were washed with a detergent without acetic peroxide; Group B uniforms were washed with a detergent containing acetic peroxide. RESULTS: Before washing, the 90 prints had an average colony-forming units (CFU) of potentially pathogenic bacteria of 68.89 per 25 cm(2) and a prevalence of: E. coli and Pseudomonas 0%, Bacillus cereus 27.78% (CI 95% ± 9.80), Clostridium and Enterococcus 2.22% (CI 95% ± 1.96), Staphylococcus aureus 21.11% (CI 95% ± 7.80). After washing, CFU was reduced to 3.09 (CI 95% ± 5.04) per 25 cm(2) in Group A and to 1.47 (CI 95% ± 4.77) per 25 cm(2) in Group B. The prevalence of specific bacteria in either group was 0%, except for S. aureus which had a prevalence rate of 4.40% (CI 95% ± 6.10) in Group A. The difference between the contamination degrees of the two groups was not significant in either test (p > 0.05). CONCLUSION: Potentially pathogenic bacteria are detectable on ambulance staff uniforms when a shift ends. Optimal prevention of bacterial infection may be achieved by daily changing, washing at a minimum of 60 degrees Celsius and use of a detergent containing acetic peroxide.

[Ambulance transportation guidelines]. / Vejledning ved ambulancetransport.

Inter-hospital transportation poses potential risks to staff and patients. The present guidelines recommend competency-based management dictated by the patient's clinical condition and medical requirements during transfer. The guidelines aim to: 1) improve patient and staff safety during transport, 2) minimize the occurrence of adverse events during transport, 3) ensure that accompanying staff are trained for and skilled in transfer and retrieval medicine and 4) encourage optimal utilisation of available competencies without unnecessarily draining hospital resources.