Development and implementation of a COVID-19 near real-time traffic light system in an acute hospital setting.

Common causes of death in COVID-19 due to SARS-CoV-2 include thromboembolic disease, cytokine storm and adult respiratory distress syndrome (ARDS). Our aim was to develop a system for early detection of disease pattern in the emergency department (ED) that would enhance opportunities for personalised accelerated care to prevent disease progression. A single Trust's COVID-19 response control command was established, and a reporting team with bioinformaticians was deployed to develop a real-time traffic light system to support clinical and operational teams. An attempt was made to identify predictive elements for thromboembolism, cytokine storm and ARDS based on physiological measurements and blood tests, and to communicate to clinicians managing the patient, initially via single consultants. The input variables were age, sex, and first recorded blood pressure, respiratory rate, temperature, heart rate, indices of oxygenation and C-reactive protein. Early admissions were used to refine the predictors used in the traffic lights. Of 923 consecutive patients who tested COVID-19 positive, 592 (64%) flagged at risk for thromboembolism, 241/923 (26%) for cytokine storm and 361/923 (39%) for ARDS. Thromboembolism and cytokine storm flags were met in the ED for 342 (37.1%) patients. Of the 318 (34.5%) patients receiving thromboembolism flags, 49 (5.3% of all patients) were for suspected thromboembolism, 103 (11.1%) were high-risk and 166 (18.0%) were medium-risk. Of the 89 (9.6%) who received a cytokine storm flag from the ED, 18 (2.0% of all patients) were for suspected cytokine storm, 13 (1.4%) were high-risk and 58 (6.3%) were medium-risk. Males were more likely to receive a specific traffic light flag. In conclusion, ED predictors were used to identify high proportions of COVID-19 admissions at risk of clinical deterioration due to severity of disease, enabling accelerated care targeted to those more likely to benefit. Larger prospective studies are encouraged.

The use of medical identification jewellery in adults with adrenal insufficiency in Australia.

OBJECTIVE: Hydrocortisone stress dosing during illness can prevent adrenal crises (AC) in patients with adrenal insufficiency (AI). When patients cannot communicate, medical identification jewellery may facilitate parenteral hydrocortisone provision but patient adoption rates are not known. DESIGN: A cross-sectional analysis of Australian medical identification jewellery subscription data. PATIENTS: Patients with AI aged 20 years and over with an active subscription to a large medical jewellery provider. MEASUREMENTS: Subscription rates by AI subtype, geographic area, age and gender. RESULTS: There were 1955 patients with AI and an active subscription in the database, corresponding to a subscription rate of 105.79/million or approximately one-third of the AI population. The subscription rate was substantially higher in primary AI (60.72/million) than secondary AI (23.16/million), corresponding to approximately 60.7% and 11.6% of the estimated population prevalence of each disorder, respectively. There was substantial variation in use by state/territory, with the highest subscribing state having a rate of over four times that of the lowest (P < 0.001). Women comprised 64.8% (n = 1266) of the group. Subscription also varied by age, being highest in the 60-69 year age group (165.15/million) and lowest in those aged 30-39 years (47.23/million) (P < 0.001). Few patients (4.8%, n = 94) mentioned, either in their record or on their jewellery, the need for urgent parenteral hydrocortisone in the event of severe illness. CONCLUSIONS: Medical jewellery is a component of AC risk reduction. However, subscription appears to be underutilised in the Australian AI population, especially among patients with secondary AI. Urgent treatment recommendations should be inscribed on the jewellery.

Medical alert tattoos-A pinch of style along with patient safety.

The use of medical tattoos can potentially be life-saving. We present a 16-year-old patient who chose to tattoo a medical condition on her forearm. Her tattoo is more extensive than most medical tattoos and shows the measures a mother will take to ensure her daughter's safety. To our knowledge, there are no published guidelines recommending an ideal location or symbology for a medical tattoo. Such guidelines would be useful to artists, as well as to medical personnel in emergencies if the patient has a tattoo.

Medical identification or alert jewellery: an opportunity to save lives or an unreliable hindrance?

Medical identification jewellery can convey vital information to emergency responders, but mistakes and ambiguity may lead to misdiagnosis and morbidity. We performed a review of relevant articles retrieved from Pubmed® , Embase® and Scopus® and Google UK Inc. to investigate the commercial availability and issuance of these products. From 84 identified studies, we shortlisted 74 for review. The Google search retrieved 1,090,000 results within 0.57 s (January 2017). We explored 32 websites selling medical alert jewellery in the first five pages of these results. We found that patients themselves are currently responsible for the engraved wording on medical alert jewellery, with no mandatory physician checks. The accuracy and appropriateness of this information may thus vary. In the absence of national guidance in the UK, we suggest that there should be a list of specific indications warranting their use, a requirement for regular review of information, and clarity around the level of physician input into the engraving chosen. We discuss the potential benefits vs. risks of wearing medical alert jewellery and clarify the limitations of medical teams' responsibilities in relation to patients found to be wearing them.

Use of emergency medical identification in the paediatric haemophilia population: a national study.

The use of emergency medical identification (EMI) such as MedicAlert(®) has been recommended for use in a variety of medical conditions; however, there is no consensus as to what form should be used and where they should be placed. There are also no uniform guidelines to direct first responders to where they should look for EMI in an emergency. The aim of this study was to identify current paediatric haemophilia nursing practice in educating families about EMI and their perceptions of patient/family adherence to using EMI. US haemophilia nurses listed on the Center for Disease Control's website received an email invitation to participate in a 30-item questionnaire posted on Survey-Monkey. Survey responses showed a wide variety of responses concerning recommendations about the form and location of EMI, particularly in the infant population. Nurses also reported that EMI was often not worn on the body and had low overall adherence. In the infant and preschool population, this was due to safety concerns, sizing, cost and parents not seeing the need for EMI. In school age and adolescents, the barrier to wearing EMI included stigma, cost and sizing. Collaboration is needed among nursing and medical staff, first responders, emergency room staff and manufacturers of EMI to develop standardized EMI which address these issues. Standard educational guidelines are needed to teach nurses and patient/families about the forms and location of EMI. Additionally, national guidelines are needed for the identification of paediatric EMI by first responders and emergency room staff.

Prevalence of and antecedents to dementia-related missing incidents in the community.

OBJECTIVE: The primary aim of this study is to examine the prevalence of and antecedents to missing incidents among community-dwelling persons with dementia. METHODS: This prospective study used mailed surveys and telephone interviews. RESULTS: The prevalence of having any incident was 0.46/year; the overall prevalence for missing incidents in this study was 0.65/year. Missing incidents had few antecedents and occurred largely when persons with dementia were performing everyday activities that they normally completed without incident. CONCLUSION: Given that a missing incident is relatively common among persons with dementia, health care professionals should assist caregivers with a missing incident plan early in the disease process. Also, as missing persons are found by persons other than the caregiver and caregivers underutilize identification devices, health care professionals may recommend the use of identification devices to facilitate a safe return.

Management of alert messages in the remote monitoring of implantable cardioverter defibrillators and pacemakers: an Italian single-region study.

AIMS: The remote monitoring of pacemakers and implantable cardioverter defibrillators (ICDs) promotes accurate supervision of the patient and device. Alert settings appear to be a crucial parameter of its efficacy. The purpose of our study was to evaluate various settings for alerts and alert message management in patients with pacemakers and ICDs. METHODS AND RESULTS: We prospectively evaluated 282 patients (181 males, 101 females, mean age 72 ± 11 years) who were referred to nine electrophysiological centres in the Veneto region of Italy for a pacemaker (76 patients) or ICD (206 patients) implant in which remote monitoring was activated (Biotronik Home Monitoring®, Biotronik, Berlin, Germany). During a mean follow-up of 382 ± 261 days, we received 106,039 transmissions. In the pacemaker group, the alerts that were most frequently activated were those concerning battery exhaustion, surveying impedances, sensing and threshold measurements, as well as missing transmissions. In the ICD/ICD-cardiac resynchronization therapy group, the alerts nearly always activated were those concerning a detection setoff, battery exhaustion, critical values of impedance, or ineffective maximum energy shock. In both groups, the alarms for heart rate monitoring and supraventricular arrhythmia were activated in fewer cases at higher variability among centres. CONCLUSIONS: Our study demonstrates that more attention is paid to critical technical data than to patients' clinical profiles, probably to limit an excessive flow of data into the centre. Accurate alert settings, personalized to the patients' features, are essential for easier and more effective management of patients who are followed remotely.

Ethical and practical concerns of surveillance technologies in residential care for people with dementia or intellectual disabilities: an overview of the literature.

BACKGROUND: Technology has emerged as a potential solution to alleviate some of the pressures on an already overburdened care system, thereby meeting the growing needs of an expanding population of seriously cognitively impaired people. However, questions arise as to what extent technologies are already being used in residential care and how ethically and practically acceptable this use would be. METHODS: A systematic literature review was conducted to explore what is known on the moral and practical acceptability of surveillance technologies in residential care for people with dementia or intellectual disabilities, and to set forth the state of the debate. RESULTS: A total of 79 papers met the inclusion criteria. The findings show that application and use of surveillance technologies in residential care for vulnerable people generates considerable ethical debate. This ethical debate centers not so much around the effects of technology, but rather around the moral acceptability of those effects, especially when a conflict arises between the interests of the institution and the interests of the resident. However, the majority of articles lack in depth analysis. Furthermore, there are notable cultural differences between the European literature and American literature whereby in Britain there seems to be more ethical debate than in America. Overall however, there is little attention for the resident perspective. CONCLUSION: No ethical consensus has yet been reached, underlining the need for clear(er) policies. More research is thus recommended to determine ethical and practical viability of surveillance technologies whereby research should be specifically focused on the resident perspective.

Standardised patient education in adrenal insufficiency: a prospective multi-centre evaluation.

OBJECTIVE: Patients with adrenal insufficiency (AI) suffer from impaired quality of life and are at risk of adrenal crisis (AC) despite established replacement therapy. Patient education is regarded an important measure for prevention of AC and improvement of AI management. A standardized education programme was elaborated for patients with chronic AI in Germany. DESIGN: Longitudinal, prospective, questionnaire-based, multi-centre study. METHODS: During 2-h sessions, patients (n = 526) were provided with basic knowledge on AI, equipped with emergency cards and sets and trained in self-injection of hydrocortisone. To evaluate the education programme, patients from eight certified centres completed questionnaires before, immediately after and 6-9 months after training. RESULTS: 399 completed data sets were available for analysis. Questionnaire score-values were significantly higher after patient education, indicating successful knowledge transfer (baseline: 17 ± 7.1 of a maximum score of 29; after training: 23 ± 4.2; P < 0.001), and remained stable over 6-9 months. Female sex, younger age and primary cause of AI were associated with higher baseline scores; after education, age, cause of AI and previous adrenal crisis had a significant main effect on scores. 91% of patients would dare performing self-injection after training, compared to 68% at baseline. An improvement of subjective well-being through participation in the education programme was indicated by 95% of the patients 6-9 months after participation. CONCLUSION: Patient group education in chronic AI represents a helpful tool for the guidance of patients, their self-assurance and their knowledge on prevention of adrenal crises. Repeated training and adaptation to specific needs, for example, of older patients is needed.

Use of a Medical-Alert Accessory in CKD: A Pilot Study.

BACKGROUND AND OBJECTIVES: Poor disease recognition may jeopardize the safety of CKD care. We examined safety events and outcomes in patients with CKD piloting a medical-alert accessory intended to improve disease recognition and an observational subcohort from the same population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We recruited 350 patients with stage 2-5 predialysis CKD. The first (pilot) 108 participants were given a medical-alert accessory (bracelet or necklace) indicating the diagnosis of CKD and displaying a website with safe CKD practices. The subsequent (observation) subcohort (n=242) received usual care. All participants underwent annual visits with ascertainment of patient-reported events (class 1) and actionable safety findings (class 2). Secondary outcomes included 50% GFR reduction, ESKD, and death. Cox proportional hazards assessed the association of the medical-alert accessory with outcomes. RESULTS: Median follow-up of pilot and observation subcohorts were 52 (interquartile range, 44-63) and 37 (interquartile range, 27-47) months, respectively. The frequency of class 1 and class 2 safety events reported at annual visits was not different in the pilot versus observation group, with 108.7 and 100.6 events per 100 patient-visits (P=0.13), and 38.3 events and 41.2 events per 100 patient visits (P=0.23), respectively. The medical-alert accessory was associated with lower crude and adjusted rate of ESKD versus the observation group (hazard ratio, 0.42; 95% confidence interval, 0.20 to 0.89; and hazard ratio, 0.38; 95% confidence interval, 0.16 to 0.94, respectively). The association of the medical-alert accessory with the composite endpoint of ESKD or 50% reduction GFR was variable over time but appeared to have an early benefit (up to 23 months) with its use. There was no significant difference in incidence of hospitalization, death, or a composite of all outcomes between medical-alert accessory users and the observational group. CONCLUSIONS: The medical-alert accessory was not associated with incidence of safety events but was associated with a lower rate of ESKD relative to usual care.

Simple triage and rapid decontamination of mass casualties with colored clothes pegs (STARDOM-CCP) system against chemical releases.

The efficiency and speed with which first responders, paramedics, and emergency physicians respond to an event caused by the release of a chemical is an important concern in all modern cities worldwide. A system for the initial triage and decontamination of victims of a chemical release was developed using colored clothes pegs of the following seven colors: red, yellow, green, black, white, and blue. Red indicates the need for emergency care, yellow for semi-emergency care, green for non-emergency care, black for expectant, white for dry decontamination, and blue for wet decontamination. The system can be employed as one of the techniques directed at improving the efficiency of decontamination in countries where there is a risk of chemical releases. It is recommended that this system should be adopted internationally and used for both drills and actual events.

Profil épidémiologique des urgences chirurgicales viscérales pédiatriques au Centre Hospitalier Universitaire de Libreville / Epidemiological profile of pediatric visceral surgical emergencies at the Libreville University Hospital Center

Objectif : Etudier les urgences chirurgicales viscérales pédiatriques au Centre Hospitalier Universitaire de Libreville (CHUL).Patients et méthodes : Il s'agissait d'une étude prospective transversale monocentrique descriptive réalisée au CHUL du 1er janvier 2018 au 30 juin 2019. Les patients âgés de 0 à 15 ans ayant présenté une urgence chirurgicale viscérale dans les services des urgences, chirurgie viscérale et thoracique et de réanimation néonatale et néonatalogie ont été inclus.Résultats : Cette étude portait sur 156 patients. L'âge moyen était de 6,67 ans avec une prédominance du sexe masculin (107/49). Quarante-deux patients étaient référés d'autres structures sanitaires. La symptomatologie évoluait depuis plus de 3 jours chez 42,3% patients. Des explorations à visée diagnostique étaient réalisées dans 145 cas, dont 90 échographies, 51 radiographies de l'abdomen sans préparation et 4 TDM. Le délai de prise en charge était de plus de 6 heures dans 82,1% cas. La pathologie la plus rencontrée était l'appendicite aigue (53 cas). Nous avions répertorié 9 décès dont 7 en post-opératoire. La durée moyenne d'hospitalisation était de 7 jours avec des extrêmes de 3 et 54 jours.Conclusion : Les urgences chirurgicales viscérales occupent une place de choix dans la pathologie chirurgicale en général et chez l'enfant en particulier. La mortalité concerne majoritairement les nouveau-nés porteurs de malformations congénitales.

Objective: To study pediatric visceral surgical emergencies at the Center Hospitalier Universitaire de Libreville (CHUL).Patients and methods: This was a descriptive single-center cross-sectional prospective study carried out at the CHUL from January 1, 2018 to June 30, 2019. Patients aged 0 to 15 years having presented a visceral surgical emergency in the emergency departments, surgery visceral and thoracic and neonatal resuscitation and neonatology were included. Results: This study involved 156 patients. The average age is 6.67 years with a predominance of the male sex (107/49).Forty-two patients were referred from other health facilities. Symptoms have evolved for more than 3 days in 42.3% of patients. Diagnostic scans were performed in 145 cases, including 90 ultrasounds and 51 unprepared abdominal xrays and 4 CT scans. The time to treatment was more than 6 hours in 82.1% of cases. The most common pathology was acute appendicitis (53 cases). We have identified 9 deaths, including 7 postoperative. The average length of hospital stay was 7 days with extremes of 3 and 54 days. Conclusion: Visceral surgical emergencies occupy a prominent place in surgical pathology in general and in children in particular. Mortality mainly concerns newborns with congenital malformations.

Epinephrine for First-aid Management of Anaphylaxis.

Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors (EAs). The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Key points emphasized include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular epinephrine injection in the mid-outer thigh reduces hospitalizations, morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine injection in community settings for patients with a history of anaphylaxis and, if specific circumstances warrant, for some high-risk patients who have not previously experienced anaphylaxis; (4) prescribing epinephrine for infants and young children weighing <15 kg, especially those who weigh 7.5 kg and under, currently presents a dilemma, because the lowest dose available in EAs, 0.15 mg, is a high dose for many infants and some young children; (5) effective management of anaphylaxis in the community requires a comprehensive approach involving children, families, preschools, schools, camps, and sports organizations; and (6) prevention of anaphylaxis recurrences involves confirmation of the trigger, discussion of specific allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, if relevant), and a written, personalized anaphylaxis emergency action plan; and (7) the management of anaphylaxis also involves education of children and supervising adults about anaphylaxis recognition and first-aid treatment.

Casualty collection in mass-casualty incidents: a better method for finding proverbial needles in a haystack.

INTRODUCTION: Mass-casualty incidents (MCIs) are on the rise. The ability to locate, identify, and triage patients quickly and efficiently results in better patient outcomes. Poor lighting due to time of day, inclement weather, and power outages can make locating patients difficult. Efficient methods of locating patients allow for quicker transport to definitive care. OBJECTIVE: The objective of this study was to evaluate the methods currently used in mass-casualty collection, and to determine whether the use of the Simple Triage and Rapid Treatment (START) triage tag system can be improved by using easily discernable tags (glow sticks) in conjunction with the standard triage tags. METHODS: Numerous drills were performed utilizing the START triage method. In Trial A, patients were identified with the triage tags only. In Trial B, patients were identified using triage tags and glow sticks. Four rounds of triage drills were performed in low ambient light for each Trial, and the differences in casualty collection times were compared. RESULTS: Casualty relocation and collection times were considerably shorter in the trials that utilized both the glow sticks and triage tags. An average of 2.58 minutes (31.75%) were saved during the casualty collections. In addition, fewer patient errors occurred during the trials in which the glow sticks were used. Between the four rounds, an average of four patient errors occurred during the trials that utilized the triage tags. However, there was an average of only one patient error for the drills when participants utilized both the triage tags and the glow sticks. CONCLUSIONS: The use of the highly visible glow sticks, in conjunction with the START triage tags, allowed for more rapid and accurate casualty collection in suboptimal lighting. The use of the glow sticks made it easier to relocate previously triaged patients and arrange for expeditious transport to definitive care. In addition, the glow sticks reduced the number of patient errors. Most importantly, there was a significant reduction in the number of patients that initially were triaged via the START method, but were overlooked during casualty collection and transport.