Scoring the Clinical Frailty Scale in the Emergency Department: The Home FIRsT Experience.

We evaluated predictors of the Clinical Frailty Scale (CFS) scored by an interdisciplinary team (Home FIRsT) performing comprehensive geriatric assessment (CGA) in our Emergency Department (ED). This was a retrospective observational study (service evaluation) utilising ED-based CGA data routinely collected by Home FIRsT between January and October 2020. A linear regression model was computed to establish independent predictors of CFS. This was complemented by a classification and regression tree (CRT) to evaluate the main predictors. There were 799 Home FIRsT episodes, of which 740 were unique patients. The CFS was scored on 658 (89%) (median 4, range 1-8; mean age 81 years, 61% women). Independent predictors of higher CFS were older age (p<0.001), history of dementia (p<0.001), mobility (p≤0.007), disability (p<0.001), and higher acuity of illness (p=0.009). Disability and mobility were the main classifiers in the CRT. Results suggest appropriate CFS scoring informed by functional baseline.

Burnout on the frontline: the impact of COVID-19 on emergency department staff wellbeing.

BACKGROUND: Burnout is a syndrome resulting from chronic workplace stress that has not been successfully managed. Healthcare professionals are particularly susceptible to this occupational phenomenon. There is limited literature currently published addressing burnout in the context of the Irish frontline workers during the COVID-19 pandemic. OBJECTIVES: Our study aims to determine the rate and degree of burnout present in the emergency department (ED) staff at St. James hospital Dublin (SJH) and at Cork University Hospital (CUH), in the context of the COVID-19 pandemic. DESIGN: A cross-sectional study was performed on a convenience sample of medical staff and healthcare staff in the ED at Cork University Hospital and St. James Hospital Dublin, two major University Hospital EDs. Burnout was measured using the Oldenburg burnout inventory (OLBI) a standardised 16-question instrument. Participants also provided demographic data and answered several questions relating to the pandemic. PARTICIPANTS: Ninety-nine participants across two departments responded (a response rate of 30%). All ED cohorts were represented. RESULTS: Burnout was identified in almost three quarters of respondents (74%). The mean burnout scores were 2.42 (OLBI cut-off 2.18). There was mean disengagement level of 2.25 and a mean exhaustion level of 2.59. There was no statistically significant variance between staff, by demographics (i.e. occupation, years working in the ED, age, or gender). There was no significant difference in burnout rates or scores between St. James Hospital, Dublin, and Cork University Hospital, though the former tended to have a higher rate of burnout at 81% vs the 67% burnout observed in CUH. CONCLUSIONS: The COVID-19 pandemic may be contributing to the long-established problem of health care burnout. The trajectory of this disease is still unclear. Consistent, progressive measures to address staff well-being, and support frontline workers, are imperative going forward.

Trends in emergency department use by older people during the COVID-19 pandemic.

PURPOSE: Reports suggest that many older people deferred seeking healthcare during the COVID-19 pandemic due to fear of contracting COVID-19. The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years. METHODS: The study site is a 1000-bed university teaching hospital with annual ED new-patient attendance of > 50,000. All ED presentations of patients aged ≥ 70 years from March to August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision. RESULTS: There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average, 4 fewer people aged ≥ 70 years presented to the ED per day in 2020. Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in 'lockdown', i.e. non-essential journeys were banned. There was a 20% reduction in patients presenting with stroke and cardiac complaints. In the 3 months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019. CONCLUSION: This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints. Given the possibility of further lockdowns, it is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

CT coronary angiography and COVID-19: inpatient use in acute chest pain service.

OBJECTIVES: CT coronary angiography (CTCA) is a well-validated clinical tool in the evaluation of chest pain. In our institution, CTCA availability was increased in January 2020, and subsequently, expanded further to replace all exercise testing during the COVID-19 pandemic. Our objective was to assess the impact of increased utilisation of CTCA on length of stay in patients presenting with chest pain in the prepandemic era and during the COVID-19 pandemic. METHODS: Study design was retrospective. Patients referred for cardiology review between October 2019 and May 2020 with chest pain and/or dyspnoea were broken into three cohorts: a baseline cohort, a cohort with increased CTCA availability and a cohort with increased CTCA availability, but after the national lockdown due to COVID-19. Coronary angiography and revascularisation, length of stay and 30-day adverse outcomes were assessed. RESULTS: 513 patients (35.3% female) presented over cohorts 1 (n=179), 2 (n=182), and 3 (n=153). CTCA use increased from 7.8% overall in cohort 1% to 20.4% in cohort 3. Overall length of stay for the patients undergoing CTCA decreased from a median of 4.2 days in cohort 1 to 2.5 days in cohort 3, with no increase in 30 days adverse outcomes. Invasive coronary angiogram rates were 45.8%, 39% and 34.2% across the cohorts. 29.6% underwent revascularisation in cohort 1, 15.9% in cohort 2 and to 16.4% in cohort 3. CONCLUSIONS: Increased CTCA availability was associated with a significantly reduced length of stay both pre-COVID-19 and post-COVID-19 lockdown, without any increase in 30-day adverse outcomes.

Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department.

BACKGROUND: Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017. AIM: To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes. DESIGN: Retrospective observational study. METHODS: We included all first patients seen by Home FIRsT between 7th May and 19th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital. RESULTS: In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 - 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 - 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 - 1.97, P=0.002). Age and sex were not predictive in any of the models. CONCLUSIONS: Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.

Opt-out screening for HIV, hepatitis B and hepatitis C: observational study of screening acceptance, yield and treatment outcomes.

BACKGROUND: We initiated an emergency department (ED) opt-out screening programme for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) at our hospital in Dublin, Ireland. The objective of this study was to determine screening acceptance, yield and the impact on follow-up care. METHODS: From July 2015 through June 2018, ED patients who underwent phlebotomy and could consent to testing were tested for HIV, HBV and HCV using an opt-out approach. We examined acceptance of screening, linkage to care, treatment and viral suppression using screening programme data and electronic health records. The duration of follow-up ranged from 1 to 36 months. RESULTS: Over the 36-month study period, there were 140 550 ED patient visits, of whom 88 854 (63.2%, 95% CI 63.0% to 63.5%) underwent phlebotomy and 54 817 (61.7%, 95% CI 61.4% to 62.0%) accepted screening for HIV, HBV and HCV, representing 41 535 individual patients. 2202 of these patients had a positive test result. Of these, 267 (12.1%, 95% CI 10.8% to 13.6%) were newly diagnosed with an infection and 1762 (80.0%, 95% CI 78.3% to 81.7%) had known diagnoses. There were 38 new HIV, 47 new HBV and 182 new HCV diagnoses. 81.5% (95% CI 74.9% to 87.0%) of known patients who were not linked were relinked to care after screening. Of the new diagnoses, 86.2% (95% CI 80.4 to 90.8%) were linked to care. CONCLUSION: Although high proportions of patients had known diagnoses, our programme was able to identify many new infected patients and link them to care, as well as relink patients with known diagnoses who had been lost to follow-up.

Burnout in the emergency department: Randomized controlled trial of an attention-based training program.

BACKGROUND: Burnout (encompassing emotional exhaustion, depersonalization and personal accomplishment) in healthcare professionals is a major issue worldwide. Emergency medicine physicians are particularly affected, potentially impacting on quality of care and attrition from the specialty. OBJECTIVE: The aim of this study was to apply an attention-based training (ABT) program to reduce burnout among emergency multidisciplinary team (MDT) members from a large urban hospital. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: Emergency MDT members were randomized to either a no-treatment control or an intervention group. Intervention group participants engaged in a four session (4 h/session) ABT program over 7 weeks with a practice target of 20 min twice-daily. Practice adherence was measured using a smart phone application together with a wearable Charge 2 device. MAIN OUTCOME MEASURES: The primary outcome was a change in burnout, comprising emotional exhaustion, depersonalization and personal achievement. The secondary outcomes were changes in other psychological and biometric parameters. RESULTS: The ABT program resulted in a significant reduction (P < 0.05; T1 [one week before intervention] vs T3 [follow-up at two months after intervention]) in burnout, specifically, emotional exhaustion, with an effect size (probability of superiority) of 59%. Similar reductions were observed for stress (P < 0.05) and anxiety (P < 0.05). Furthermore, ABT group participants demonstrated significant improvements in heart rate variability, resting heart rate, sleep as well as an increase in pro-inflammatory cytokine expression. CONCLUSION: This study describes a positive impact of ABT on emergency department staff burnout compared to a no-treatment control group. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02887300.

Towards prompt electrocardiogram acquisition in triage: Preliminary testing of a symptom-based clinical prediction rule for the Android tablet.

BACKGROUND: For patients with suspected acute coronary syndrome, international guidelines indicate that an Electrocardiogram (ECG) should be performed within 10 min of first medical contact, however success at achieving these guidelines is limited. AIMS: The purpose of this study was to develop and perform initial testing of a clinical prediction rule embedded in a tablet application, and to expedite the identification of patients who require an electrocardiogram within 10 min. METHODS: This derivation of the Acute Coronary Syndrome Application (AcSAP) comprised of three local studies, an unpublished audit and literature critique. The AcSAP was prospectively tested over four months in patients presenting to the Emergency Department (ED) of a Dublin teaching hospital. An audit form retrieved data pertaining to times of: registration to the emergency department, triage, first electrocardiogram and diagnosis. The AcSAP was subsequently evaluated by experienced triage nurses ( n=18) who had utilised it. RESULTS: The AcSAP was activated 379 times. Patients with ST Elevation Myocardial Infarction (STEMI) and non-ST Elevation Myocardial Infarction (NSTEMI) were significantly more likely to return a categorisation of 'immediate ECG' or 'ECG within 10 min' ( p<0.001). There was a significant difference in 'triage to ECG' times across categories, the 'immediate ECG' categorisation resulting in the shortest time ( p=0.002). Evaluations suggest that staff found the tool quick and easy to use and results seemed accurate. CONCLUSION: Testing of the AcSAP suggests that it accurately identifies patients who require an ECG within 10 min. As such, it has the potential to support the meeting of clinical guidelines for ECG acquisition.

Mantra meditation programme for emergency department staff: a qualitative study.

OBJECTIVES: Rates of burnout and stress in healthcare practitioners are steadily increasing. Emergency department (ED) staff are particularly susceptible to such poor outcomes. Mantra meditation (MM) may contribute to increased well-being. The primary aim of this study was to obtain indepth qualitative feedback on ED staff's experience of a MM programme. A secondary objective was to harness staff's perception of the ED working environment. DESIGN: Qualitative study. SETTING: ED in St James' Hospital, Dublin, Ireland. PARTICIPANTS: Doctors, nurses, allied health professionals and administrative staff (n=10, eight women, mean age 35.6 years) working in the ED who attended a MM programme. METHODS: Semistructured interviews were conducted by a trained independent researcher. Interviews were transcribed and thematically analysed. RESULTS: Five main themes and six subthemes were identified: work pressure and perceived stress; perceived benefits of meditation (with subthemes of increased attention/awareness, improved emotion regulation and new coping mechanisms, relaxation and sleep quality); conflicting attitudes to practice; barriers to meditation practice (with subthemes of schedule, length of practice and individual differences); and facilitators to practice. CONCLUSION: ED staff in this study described the demands of their work and voiced a need for a workplace well-being programme. Our findings suggest that MM might represent a viable tool to develop attention and awareness, improve emotion regulation and improve their capacity to cope with stress, which may impact their workplace well-being, wider health service, patient safety and quality of care. Support from the organisation is considered to be integral to embedding of a workplace well-being programme, such as the practice of meditation into their daily lives.

Malarial cases presenting to a European urban Emergency Department.

INTRODUCTION: Malaria accounts for approximately 225 million infections and 781 000 deaths annually worldwide. Malaria should be considered in the Emergency Department as an important cause of illness in returning travellers. We were interested in evaluating the malarial caseload presenting to an urban inner city Emergency Department in terms of the nature and severity of clinical presentations. METHODS: A retrospective study of all cases of malaria presenting to our Emergency Department from 1 January 2004 to the 31 December 2010 was conducted. Information about patient demographics, areas in which malaria was contracted, clinical course, treatment and complications was recorded from chart reviews. RESULTS: Fifty-six cases of malaria were diagnosed in the period studied. The majority of patients had falciparum malaria (80%), were originally from West or Central Africa (75%), were mainly from Nigeria (48%), and were visiting friends and relatives in their country of origin. A total of 79% had not taken appropriate antimalarial chemoprophylaxis. A total of 7% were classified as severe malaria according to the WHO criteria. There was one death. CONCLUSION: Malarial cases occurred predominantly in immigrants who were returning to endemic areas to visit friends and relatives in their country of origin. The majority of patients did not undergo antimalarial prophylaxis. Severe malaria is a medical emergency requiring urgent recognition and appropriate antimicrobial and critical care therapy. Improving public awareness and healthcare promotion regarding risks of travel-related malaria may help to improve compliance with prophylaxis and preventative measures, and thereby reduce the prevalence of malarial infection in this group.

Venous vs arterial blood gases in the assessment of patients presenting with an exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: The purpose of this study was to investigate the clinical correlation between arterial and venous blood gas (VBG) values in patients presenting to the emergency department (ED) with acute exacerbation of chronic obstructive pulmonary disease. METHODS: A prospective study of patients with chronic obstructive pulmonary disease presenting to the ED with acute ventilatory compromise was done. Patients were included if their attending physician considered arterial blood gas sampling important in their initial assessment. Data from arterial and venous samples were compared using Spearman correlation and bias plot (Bland-Altman) methods. RESULTS: Ninety-four patients were enrolled in the study. Eighty-nine patients had complete data sets for analysis. Arterial hypercarbia was present in 30 patients (33.7%; range, 51-140.19 mm Hg). All cases of arterial hypercarbia were detected using VBG sampling when a screening cutoff of 45 mm Hg was applied (sensitivity, 100%; 95% confidence interval, 88.7%-100% and specificity, 34%; 95% confidence interval, 23.1%-46.6%). Bias plot revealed moderate agreement between arterial and venous Pco(2) with an average difference of 8.6 mm Hg and 95% limits of agreement of -7.84 to 25.05 mm Hg. For pH, mean difference between each group was 0.039 (range, -0.12 to 0.03). Linear regression analysis for pH demonstrated very close equivalence with a regression coefficient of 0.955, and Spearman correlation showed significant correlation of 0.826 (P = .001). CONCLUSION: Venous pH and HCO(3) values show excellent correlation with arterial values. Using a previously validated screening cutoff of 45 mm Hg, venous CO(2) has 100% sensitivity in detecting arterial hypercarbia. There is insufficient agreement between venous and arterial CO(2) for VBG to replace arterial blood gas in determining the degree of hypercarbia.

Severe dental infections in the emergency department.

A dental source of infection should be suspected in patients presenting with an acute cervicofacial swelling or trismus. Dental infection originates in the tooth or in the tissues that closely surround it. These infections are common and generally resolve by spontaneous drainage through the gingival tissues of the tooth. Severe dental infections extend beyond the jawbone into potential spaces around the jaw and into the neck. The spread of infection can lead to life-threatening complications, such as airway compromise, cavernous sinus thrombosis, and mediastinitis. Mortality from severe dental infections, although uncommon, is increasing. The aim of this review was to describe the clinical presentation, evaluation, and management of patients presenting with severe or potentially severe dental infection.

Conservative management of azygous vein rupture in blunt thoracic trauma.

We report a case of successful conservative management of acute traumatic rupture of the azygous vein. A 48-year-old male was involved in a motor vehicle collision. Primary survey revealed acute right intrathoracic haemorrhage. He remained haemodynamically stable with rapid infusion of warmed crystalloid solution and blood. Computed tomographic imaging showed a contained haematoma of the azygous vein. The patient was managed conservatively in the intensive care. Azygous vein laceration resulting from blunt thoracic trauma is a rare condition that carries a universally poor prognosis unless the appropriate treatment is instituted. Clinical features include acute hypovolaemic shock, widened mediastinum on chest radiograph, and a right-sided haemothorax. Haemodynamic collapse necessitates immediate resuscitative thoracotomy. Interest in this injury stems from the severity of the clinical condition, difficulty in diagnosis, the onset of a rapidly deteriorating clinical course all of which can be promptly reversed by timely and appropriate treatment. Although it is a rare cause of intramediastinal haemorrhage, it is proposed that a ruptured azygous vein should be considered in every trauma case causing a right-sided haemothorax or widened mediastinum. All cases described in the literature to date involved operative management. We present a case of successful conservative management of this condition.

Complications of heroin abuse.

A 21-year-old man presented to the emergency department in St James's Hospital by ambulance. He was found collapsed at home by his uncle. He was complaining of severe pain and swelling to his left lower limb, with reduced sensation to his left foot. He was hepatitis C positive from intravenous drug use, and had most recently used both heroin and cocaine 5 days previously on his release from prison. Musculoskeletal exam showed extensive swelling of his left lower limb, with tense calf compartments. Initial laboratory results showed a raised creatine kinase of more than 155,000 IU/l. Urine toxicology was positive for methadone, heroin and benzodiazepines, whereas urinary dipstick was positive for blood, which was confirmed to be myoglobin by subsequent laboratory analysis. Atraumatic rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents, that is myoglobin and creatine kinase. Drugs have direct toxic effects, but may also cause coma-induced rhabdomyolysis, owing to unrelieved pressure on gravity-dependent body parts. Diagnosis is made with history (i.e. recent heroin or cocaine use), elevated serum CK, plus the possible presence of myoglobinuria. Aggressive i.v. rehydration remains the mainstay of treatment. If there is any evidence of compartment syndrome, urgent fasciotomy is required. Electrolyte imbalances should be corrected, unless very mildly abnormal. We have learned from our experience with this case that a high index of suspicion and thereby early recognition is crucial to prevent complications in intravenous drug users presenting with unusual symptoms and signs.

An unusual cause of headache: Pott's puffy tumour.

Osteomyelitis of the frontal bone (eponymously known as Pott's puffy tumour) is an extremely rare and potentially life-threatening complication of frontal sinusitis. The entity was first described by Sir Percival Pott, an 18th century neurosurgeon. It is today considered a historical vignette with the introduction of modern antimicrobial agents. Early diagnosis and immediate active treatment are necessary to prevent severe neurologic sequelae. We report on a case of Pott's puffy tumour in a previously healthy young man with a progressively worsening headache and swelling of the frontal bone. Computed tomography and magnetic resonance imaging revealed features characteristic of this condition. Following emergency sinus trephination and 6 weeks of parenteral and enteral antibiotic therapy, the patient achieved a complete recovery.

Ankle fractures: emergency department management...is there room for improvement?

OBJECTIVE: The aim of this study was to identify pitfalls in the acute management of ankle fractures which were referred to a regional orthopaedic unit. This unit provides orthopaedic services for the catchment area of the Waterford Emergency Department together with three additional emergency units in the south-eastern region of Ireland. METHODS: This is a retrospective study of all patients referred to the Waterford Regional Orthopaedic service from 1 January 2001 to 31 December 2001 for management of acute ankle fractures. RESULTS: A total of 236 patients were identified during the study period. Open reduction and internal fixation were performed in 200 cases. In all, 52% of patients had definitive surgery within 24 h of their injury. These patients were evenly distributed between regional (64%) and peripheral (60%) emergency unit referrals. 24% of patients required essential manipulation prior to surgery. This had been performed in only 34% of cases prior to transfer. Two patients were transferred with a pulseless foot. CONCLUSIONS: Ankle fractures are a common musculoskeletal injury seen in emergency departments and minor injury units. Long-term disability resulting from ankle fractures can be reduced by optimal early management procedures. This is an important area for consideration in education programmes in emergency medicine.

Descending polyneuropathy in an intravenous drug user.

A 27-year-old male intravenous drug user presented to the Emergency Department of St James's Hospital with a 1-week history of progressive dysphasia, dysphagia and difficulty 'holding his head up' and 'keeping his eyes open'. He also complained of increasing weakness in his upper limbs, as a result of which he kept dropping things. He was on a methadone program but was using both intravenous heroin and cocaine at the time of presentation. Examination of his motor function revealed generalized hypotonia, hyporeflexia and reduced power in both upper limbs. No sensory loss was observed. Co-ordination was intact. The clinical picture of a proximal symmetrical descending weakness and an absence of sensory loss was suggestive of botulism. Clostridium botulinum is a spore-forming, obligate anaerobe. The three forms of human botulism are food-borne, wound and intestinal. A fourth man-made form is produced from aerosolized botulinum toxin and results in inhalational botulism. A little as 1 g of aerosolized botulinum toxin has the potential to kill 1.5 million people. Toxin is detected in serum or stool specimens in only approximately 46% of clinically diagnosed cases. Treatment involves supportive care and early passive immunization with equine antitoxin. Patients should be regularly assessed for loss of gag and cough reflex, control of oropharyngeal secretions, oxygen saturation, vital capacity and inspiratory force. When respiratory function begins to deteriorate, anticipatory intubation is indicated. Early symptom recognition and early treatment with antitoxin are essential in order to prevent mortality, and to prevent additional cases, it is important to ascertain the presence of similar symptoms in contacts of the patient and local public health officials must be notified as one case may herald an outbreak. Given the continued threat of bioterrorism, the Centre for Disease Control Surveillance System in the United States must also be notified of any cases of botulism.