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Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
MEETING ABSTRACTS
Open Access
Proceedings of the 5th Danish Emergency
Medicine Conference
Aarhus, Denmark. 18-19 April 2013
Edited by Christian Skjærbæk
Published: 9 September 2013
These abstracts are available online at http://www.sjtrem.com/supplements/21/S2
MEETING ABSTRACTS
A1
A mixed methods observational simulation-based study of
interprofessional team communication
Charlotte Paltved1*, Kurt Nielsen1, Peter Musaeus2
1
SkejSim Medical Simulation and Skills Training, Aarhus, Denmark; 2Centre for
Medical Education, Aarhus University, Aarhus, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A1
Background: Interprofessional team communication has been identified
as an important focus for safety in medical emergency care. However, indepth insight into the complexity of team communication is limited.
Video observational studies might fill a gap in terms of understanding
the meaning of specific communication interactions and link team
performance to patient outcome.
This study had two aims. First, to develop a theory-based evaluation
instrument that measures and qualifies team communication. And second,
to investigate the quality and content of summaries and re-evaluations
evolving step wise and progressively when treating the critically ill patient.
Methods: The study used mixed methods. The research question sets out
to identify which factors most strongly mediate effective and safe team
performance.
Team communications were video observed in 29 scenarios. Data analysis
employed a grounded theory approach. Communication events and
communication failures were recorded and classified into four categories.
Furthermore, data supported the building of the SkejSim Team Step
Model that captures and conceptualizes the quality of summaries and reevaluations.
Results: In the 29 simulations, 1091 communication events and 58
communication failures were recorded and classified. Failure types included
“occasion” where timing was suboptimal, “content” where information was
inaccurate or missing, “purpose” where issues were not resolved, and
“audience”, where a key team member was not present. Two thirds of these
failures resulted in visible effects: inefficiency, delay, tension, and procedural
error.
Teams were found to differ and these differences could be explained
using the five-level model.
Conclusion: The study found that complex interprofessional team
communication does not readily reduce to mere observation and
recording of events. An interpretative approach is required to meaningfully
account for communication exchanges in context. Despite the complexity
of interprofessional team communication, the integration of these two
models might provide a significant framework for the construct of efficient
team performance. This research has advanced evaluation of team
communication, by allowing us to recognize and represent communication
by complexity rather than by reductionism and oversimplification. Yet,
each aspect is definable and easy to explain and demonstrate to clinicians
and thus, holds the promise for simulation-based team training to improve
interprofessional team communication.
A2
Characteristics of patients not clinically recognized as suffering from
bacteriaemia
Anders Johan Orland Rasmussen*, Anne Grethe Mølbak,
Jacob Hansen-Schwartz
Emergency Department Køge Sygehus, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A2
Background: Criteria for Systemic Inflammatory Response Syndrome
(SIRS) are recognized as operational criteria for detecting a possible
bacteriaemia. Given the sensitivity and specificity of the criteria, clinical
judgment is crucial in detecting the condition. The aim of the study was
retrospectively to identify clinical characteristics of patients not primarily
thought of as having bacteriaemia, yet harboring the condition.
Methods: Consecutive blood cultures sampled in relation to admittance
through the Emergency department from 2010 to 2012 were identified. 1615
blood cultures were identified of which 229 (14%) were positive. Group 1
were sampled on admittance where a pathogen was cultured (171 patients,
‘true positive’), group 2 on admittance where a contaminant was cultured (35
patients, ‘false positive’), group 3 were not sampled on admittance, but
subsequently during hospital stay and where a pathogen was cultured (23
patients, ‘false negative’), and group 4 on admittance where culture was
negative (1386 patients, ‘true negative’). At random 90 patients from group 4
were selected for analysis.
Parameters recorded: Age, gender, vital signs, white blood cell count,
bacterial species, and focus. Presence of diabetes, liver disease, kidney
disease, chronic obstructive lung disease and cardiac disease was registered.
Results: Significant differences between group 1 and 3:
Temperature: Group 1: 38.3 (34.2–41.2), group 3: 37.7 (36.2–40.2)
RespiratoryrRate: Group 1: 21 (5–46), group 3: 18 (11–33)
Saturation: Group 1: 95.9% (32–100), group 3: 97.5 (range 92–100)
No significant difference among groups regarding species and focus was
observed. In group 3 we identified a significantly higher proportion of
patients with hepatic disease and alcohol abuse, and a tendency for a
higher proportion of patients with known malignant disease.
In group 1 78% and in group 3 22% fulfilled the SIRS criteria.
Conclusion: 11% of the patients suffering from bacteriaemia in our cohort
were not clinically detected in the Emergency Department. Vital
parameters were within normal range underscoring the difficulty to detect
© 2013 various authors, licensee BioMed Central Ltd. All articles published in this supplement are distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
these patients. The study warrants attention regarding bacteriaemia in
patients suffering iver disease and possibly also patients with known
malignant disease.
A3
Emergency department flow in an optimized setting
Lars L Stubbe Teglbjærg
Svendborg Emergency Department, FAM Svendborg, OUH Svendborg
Hospital, DK 5700 Svendborg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A3
Background: The patterns of patient admission and discharge rarely
reflects patient needs. The main reason is the way we manage processes
such as ward rounds, operations, radiology, outpatient handling, inpatient
tests etc. This results in variable length of stay (LoS) in the emergency
departments, even among patients admitted with similar conditions. We
have implemented structured time-driven patient handling with five key
elements: 1. Compilation of acute patients in a single joint acute ward.
2. Fast Track treatment of minor injuries. 3. Within a four-hour time limit a
specialist-level treatment-directing diagnosis and treatment plan has to be
made for patients admitted for inpatient treatment. 4. A discharge plan has
to be made for in-patients with an estimated date of discharge within the
same 4-hour time limit. 5. Adjustment of staffing, operation capacity,
laboratory and radiology service according to patient flow. The purpose of
the change was to secure uniform, fast, high quality diagnosing, care and
treatment for all acute patients, 24 hours a day.
The objective of this study was to describe effects of a structured, time
driven approach on patient flow.
Methods: Data were obtained from our patient administrative system
(FPAS) and our patient logistic system (Cetrea Emergency). Main outcome
measures were average time to treatment initiation in the Emergency Room
(ER), percentage of patients who finishes treatment in the emergency
department (ED) and LoS for patients in the ED.
Results: Following actual intervention, registered average time to
treatment initiation for ER patients decreased more than 50% to less than
30 minutes.
The percentage of patients registered as having been discharged directly
from the emergency department was 79,3%.
Average LoS in the ED was 6,1 hours, 12,3 hours for inpatients and 2,8 hours
for ER outpatients.
Conclusion: Structured intervention reduced registered time to treatment
initiation in this setting. The setting enables diagnosis and definitive
treatment of most acute patients. The results suggest further work in the
analysis of quantitative effects of structured process changes in the handling
of acute patients. Whether structured flow with mandatory structured
treatment and discharge plans enhances treatment quality or initiates a
‘self-fulfilling prophecy’ warrants further investigation.
A4
Epidemiology of moderate and severe traumatic brain injury in Cairo
University Hospital in 2010
Tamer Montaser1,3*, Ahmed Hasan2, Ahmed Ibrahim1
1
Cairo university hospital, Cairo, Egypt; 2King Khaled University Hospital,
Kingdom of Saudi Arabia; 3Shobra General Hospital, Cairo, Egypt
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A4
Background: Traumatic Brain Injury (TBI) is a contributing factor to
approximately one third of all injury-related deaths in USA annually.
Updated statistical records for TBI in Egypt are lacking. The current research
is aiming for estimating the prevalence of TBI in Egypt in order to develop a
comprehensive TBI prevention program.
Methods: One year period (one calendar month every quarter of 2010)
descriptive epidemiological study of moderate and severe TBI cases
admitted to the emergency department, Cairo main university hospital. The
Data collection sheet included personal data (age, sex and residency),
incident related data (cause, nature and time of injury) and both; clinical and
radiological findings.
Page 2 of 17
Results: Moderate and severe injuries account for 17.2% (844) of all TBI
presented cases in the 4 months for the study. Male sex was predominantly
affected 79% of cases. 63% of the cases were between 19 and 55 years old
and the 2 main causes were fall from height (FFH) and motor vehicle
collision (MVC) which account for about 64% of cases. 17% of cases were
among pediatric group (1-18 years) and FFH was the leading cause with 34%
followed by MVC and stuck by or against events with the same percentages
(21%). Causes of moderate and severe TBI among seniors (above 60 years)
were FFH (28%), MVC (24%), and Stuck by or against events (15%).
Conclusion: Traumatic brain injury is a serious public health problem in
Egypt. Further data interpretation over wider periods of time should be
conducted for better understanding of TBI prevalence is highly recommended
to develop effective injury prevention program. Inefficient recording should
raise the concern to establish an optimal system for data recording and
interpreting.
A5
Evaluation of potential factors compromising the use of electronic
whiteboards 17 month after their implementation in Slagelse
Emergency Department
Stine Vestergaard Elbæk1, Tim Løye Møller2, Gustav From1*
1
Emergency Department, Slagelse Hospital, Slagelse, Denmark; 2Humanistisk
Teknologisk Studie, Roskilde University, Roskilde, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A5
Background: Emergency departments (ED) have recently been established
throughout Denmark, and their organization is still under transformation.
The departments are characterized by a high turnover of staff. To ensure
quality of care and efficiency of work electronic whiteboards (EW) have been
implemented. The EWs create an overview allowing staff to assess who need
care the most and to coordinate resources. May 2011 EWs were
implemented at Slagelse ED, and a guideline for its use was written.
The aim of this study was to detect potential factors compromising the use
of EWs in its operational phase 17 months after implementation.
Methods: The study was designed as a qualitative study using observations
and interviews to collect data.
November 2012 four external surveyors, students from University of
Roskilde, made 20 hours of observations of physicians, nurses and
secretaries during 3 days. 3 physicians (consultant, staff specialist, and junior
doctor) and 3 nurses (leader, coordinating and clinical) were interviewed.
Results: An inconsistency in the use of the EWs was observed causing
challenges in the daily workflow. Disagreements on what should be
registered, and by who and when were also observed.
Both physicians and nurses thought that the inconsistency in use was
caused by two factors: firstly, the lack of a detailed mutually accepted
guideline dictating who was responsible for the different functions and for
registration of different types of information on the board, and secondly,
limited introduction of the systems functionality to new staff.
Conclusion: The study showed inconsistency in the staffs’ use of the EWs in
its operational phase. The study suggested that this might be remedied by a
regularly adjusted and mutually accepted guideline for use of EWs and a
continuous thorough educational effort on new staff.
A clear guideline facilitates a better introduction and a better introduction
contributes to implementation and maintenance of the guidelines, which
means the two interventions enhance each other on the staffs’ use of the EW.
The study warrant further studies in Slagelse ED and EDs elsewhere to show
if inconsistent use and outdated guidelines are widespread and to show if
updated guidelines and education can stabilize the use of EWs.
A6
Management of acute alcohol withdrawal in the setting of a quick
diagnostic unit integrated in an emergency department setting
Pernille Würtz Bøhm*, Tove Beyer Fuglevig Mortensen,
Thomas Andersen Schmidt
The Emergency Department, Holbæk Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A6
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
Background: Alcohol consumption can have adverse social, legal,
occupational, psychological, and medical consequences. The prevalence
of alcohol-use disorders is high in Emergency Departments. The novel
establishment of a Quick Diagnostic Unit (QDU) in an ED setting has
allowed expeditious and focused, medically supervised acute alcohol
withdrawal. The purpose of the study was to describe the alcohol-use
disorder clientele and treatment in this new setting.
Methods: Chart review of an 8 month period April to December 2012.
Values were given as means ± SEM. Significance was evaluated using
Student’s two-tailed t-test for unpaired observations or Fisher’s exact test
as appropriate. The level of significance was established at p < 0.05.
Results: A total of 91 patients were included in the study, 74 men and 17
women. The patients in total amounted to 2.6% of the discharged patients
from the QDU. There was no age difference between men and women, i.e.
51.2 ± 1.5 years vs 50.6 ± 2.5 years (p > 0.80). Length of stay was 1.8 ± 0.2
days for men vs 2.5 ± 0.6 days for women (p > 0.2). In 19% of the cases men
held jobs, whereas none of the women were employed (p < 0.0001).
Among patients who received chlordiazepoxide (RisolidR) for withdrawal
symptoms the total dose was 405 ± 43 mg (n = 53) among men vs 494 ±
105 mg (n = 14) among women (p > 0.30). Thus 72% of the men vs 82%
(p > 0.10) of the women were in need of chlordiazepoxide. There were no
differences between men and women with regard to need for ICU care or
emergent psychiatric referral (p > 0.20). Men left the QDU against medical
advice to a greater extent than women, i.e. 22% vs 6% (p < 0.002).
Conclusion: Women with alcohol-use disorders appear to be more
marginalized than men. Thus, they are employed to a lesser extent than
men, and numerically they are treated more frequently and with a higher
total dose of chlordiazepoxide. Men are more capable or prone than women
to reject treatment. Further studies of the QDU setting would be beneficial.
A7
Normal temperature upon admission does not influence on timing of
antibiotics for septic patients
Anne-Katrine Bertelsen1,3*, Julie Mackenhauer1,3, Nina Buch1,3, Helle Nibro2,3,
Hans Kirkegaard1,3
1
Research Center for Emergency Medicine, Aarhus University Hospital,
Denmark; 2Intensiv Terapi Afsnit (ITA), Aarhus University Hospital, Denmark;
3
The CONSIDER sepsis network, Research Center for Emergency Medicine,
Aarhus, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A7
Background: Early identification and treatment of sepsis is essential for
prognosis and outcome. Sepsis is a complex syndrome based on nonspecific symptoms, making early identification a medical challenge.
Elevated or lowered bodytemperature often release a blood culture. Our
hypothesis is, that a lack of temperature upon admission influence on the
time of diagnosis and thereby time of antibiotics.
Methods: Our cohort is a part of a larger clinical database of septic patients
identified through a prospective screening of all patients admitted to the
intensive care unit (ICU) at Aarhus University Hospital from Nov 2008 - Sep
2010. Patients above age 18 admitted directly from the Emergency
Department (ED) to the ICU with severe sepsis or septic shock were included.
We compared patients with elevated (≥38°C) or lowered (≤36°C)
bodytemperature to patients who demonstrated a normal temperature upon
admission to the ICU, relative to initiating empirical antibiotic treatment.
Results: A total of 180 septic patients were admitted to the ICU directly
from the ED.
161 had a temperature registered upon arrival to the ICU. 52% had an
abnormal temperature.
There were no difference regarding age and gender between the two
groups. Overall in-hospital mortality was 21,1%.
Comparing patients with abnormal temperature to patiens with normal
temperature upon admisssion, we found no difference in timing of
antibiotics. 53% of the patients with abnormal temperature recieved
antibiotics in the ED, while 47% of the patients with normale temperature
recieved antibiotics prior to admission to the ICU (p=0,62), The remainding
recieved antibiotics in the ICU.
Comparing our findings to local guidelines for ”timely antibiotics”, 67%
with abnormal and 64% with normal temperature recieved antibiotics
according to the guidelines.
Page 3 of 17
Conclusion: In a population of septic patients admitted directly from the
ED to the ICU, we found no difference in timing of antibiotics between
patients with normal temperature and patients with abnormal temperature
upon admission. Increasing focus on sepsis, and use of other clinical
indicators of infection may contribute to our findings. Only 2/3 of the
population recieved timely antibiotics accoring to local guidelines for
sepsis treatment.
A8
Primary triage in ED
Vibeke Hald, Marianne Barylak*
Akutafdelingen Nykøbing F, 4800 Nykøbing F, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A8
Background: Clinical effectiveness and patient safety depends on
standardization of the triage process. Through 4 years, nurses in our
department have trained and used a 5-level national recommended triage
model. A former study three years ago in our department showed variations
in the triage evaluation between nurses with a kappa value at 0.45.
Therefore, a new study was made to evaluate the accuracy of triage
between nurses.
Methods: Observational study of the triage praxis of 25 nurses, evaluated
with audit of the electronic documentation of the triage process. Audit was
performed using a set of explicit indicators every week with a sample of 20
patients in a 12 weeks period. The indicators were defined due to our
standard protocol for triage. The following data were registered; name of
the triage nurse, triage colour, and which observations the triage score was
based on either vital signs, diagnosis or clinical evaluation. Data was
cumulated and evaluated to identify if the nurses performed equally due to
the standard.
Results: Patients were mainly triaged due to vital signs 75%, 20% were
triaged due to diagnosis and a smaller group 5% was triaged due to clinical
evaluation. The main group of nurses had the same pattern of performance.
Few nurses did only triage on the basis of diagnosis and forgot the vital
signs, especially sepsis criteria.
Conclusion: Triage determines to a large extend the resources committed
to the patients in an ED. Therefore it is essential to know how equally the
nurses perform triage. We observe that after three years of experience and
training including classroom education, the majority of nurses use the
standard principles of triage. Few nurses need greater insight and clarity, to
distinguish between a given diagnosis and symptoms of serious illness.
A9
Sepsis screening - a cross-sectional study from the Emergency
Department Region Hospital Horsens
Nikolaj Raaber1*, Carsten Brandt1, Liselotte Fisker2
1
Emergency Department, Region Hospital Horsens, Denmark; 2Department of
Endocrinology University Hospital Aarhus THG, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A9
Background: As a part of The Danish Safer Hospital Programme Regional
Hospital Horsens introduced the Sepsis package in 2011 in order to reduce
unnecessary deaths and harm to patients.
With this study we show how the goals defined in the Sepsis package
including 5 elements are met in the Emergency Department Regional
Hospital Horsens and how this affects the morbidity of septic patients. At
the same time we examined which patients with sepsis who didn’t get
screened for sepsis.
Methods: Study design: Cross sectional study.
We retrospectively reviewed the journals of all patients with af medical
condition age >15 years who were admitted to the Emergency Department
Regional Hospital Horsens in April 2012.
Results: After thorough review of data from Opus Electronic Patient
Journal we found that almost all patients with sepsis (22 of 29) had
received all 5 elements of the Sepsis package (fluid resuscitation,
antibiotics, cultivation, lab tests and screening for severe sepsis) but only
12 met all goals after 6 hours (the 6 hour bundle). We found 13 patients
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
(45%) with severe sepsis/septic shock out of which 4 died corresponding
to 31% of patients with severe sepsis/septic shock.
Conclusion: Our data suggests that the implementation of all elements in
the Sepsis package are difficult to achieve and that there is place for
improval in the Emergency Department Regional Hospital Horsens. To
change this a goal directed effort among the staff is needed.
The mortality among septic patients doesn’t seem to have been reduced
after implementing the Sepsis package, the number of patients in this study
is too small to make any final conclusions.
By enlarging the study to greater number of patients and including a
historical control group it will be possible to evaluate the impact of the
Sepsis package.
Real time easy registration of observations and treatments are also
necessary if better results are to be achieved concerning compliance to
all elements of the six hour bundle.
A10
Triage and vital signs in a population discharged from and readmitted
to the ED
Ida Helsø1, Helle Ipsen2, Claus Heinecke3, Hanne Jørsboe2*
1
Medical Department, Nykobing F Hospital, Denmark; 2Emergency
Department, Nykobing F Hospital, Denmark; 3Department of Quality
Improvement, Nykobing F Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A10
Background: In our community hospital about 20% of the patients are
readmitted within 30 days to the emergency room, where clinical
effectiveness and patient safety depend on the triage process including
observation of vital signs. Therefore, the study was performed to describe
this population and to compare the triage score and vital signs at the
first contact and at readmission.
Methods: Patients were identified from a national database and evaluated
through an audit of electronic patient files with registration of the following
criteria; triage-level, vital signs, medical problems and diagnosis,
supplemented with the vital signs monitored the last day before discharge
from the first hospitalization. The vital signs were summarized to a
standardized score called BOS. The triage system is a 5 point-scale in
colours, where 1 compared to “red” resuscitation. Data were evaluated with
a Mann-Whitney non-parametric statistic for paired data.
Results: A sample of 50 cases were included (26 F, 24 M), mean age 57
years (21-92) of which 64% of the patients had co-morbidity. Most of the
patients were admitted with symptoms of abdominal pain (20%), dyspnoea
(14%) and alcohol related disease (10%). At readmission, 58% patients had
related symptoms. The average triage score at the primarily contact were
urgent (mean: 3 (1-4)) and BOS score 1 (0-5), which was reduced through
stabilization to 0 (0-3) (p<0.05). At readmission, the triage score was 3 (2-4)
and BOS level was increased to 1 (0-5). 22% of the patients evaluated by
triage had a higher degree of acuity compared to the first contact,
supported by 33% of the patients were evaluated worsened by vital signs
(BOS).
Conclusion: These data suggest a relative young population is
readmitted to the ED compared to international studies. A part of these
patients with a high degree of co- morbidity, were evaluated urgent by
triage and BOS at readmission, despite stabilization before discharge from
the first hospitalization. Further audit will be extended to a larger
population.
A11
A biological Bayesian network for prediction of adverse outcome in a
population of acutely ill patients triaged in the Emergency Department
Charlotte Barfod1*, Lars Hyldborg Lundstrøm1, Kai Henrik Wiborg Lange1,
Kristen Barfod2
1
Deparment of Anaesthesiology and Intensive Care Medicine, Nordsjællands
Hospital Hillerød; 2National Food Institute, Technical University of Denmark,
Copenhagen
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A11
Page 4 of 17
Background: We know from previous studies that increasing age,
abnormal vital signs and abnormal acid-base status are strongly associated
with in-hospital mortality in unselected patients admitted acutely to
hospital. A model including this information will make us able to explore
associations and predict the risk for future patients. Our aim was to
describe a Bayesian model for prediction of adverse outcome in the acute
ill adult patient admitted to hospital, based on already existing data from
the ‘Acute Admission Database’.
Methods: The model is a static Bayesian network, i.e. a stochastic model
where all interdependence is described by conditional probabilities. The net
consists of nodes representing variables and pointed arrows of influence.
The probabilities connected to the nodes and arrows are conditional
probabilities showing how the state of a variable influences the probability
distribution for the states of another variable. We based the model on
already existing data from the ‘Acute Admission Database’ and imported
data from 6279 patients consecutively admitted to Hillerød Hospital through
the Emergency Department into the Bayesian net program, Netica “3.7” ©
Norsys Software Corp. We included the risk factors identified in this cohort
in previous studies as nodes, and represented the known associations with
directed arrows.
Results: We tested the use of the model by simulating the path of an
acutely ill patient: a male patient, 70 years old and presenting with
vomiting blood. By using this evidence in the nodes of relevance, we could
assess the most probable distribution of the other nodes, including the
outcome of interest. We simulated that more data became available for
instance vitals signs and triage categories. This new evidence changed the
nodes and finally we entered information about a venous blood gas, which
changed the probability distribution of the outcome measures as more
evidence was gained.
Conclusion: By using already existing data, we were able to build a
Bayesian network, which can be used to estimate the risk of adverse
outcome and serve as a decision support system in assessing future patients
admitted acutely to hospital.
A12
A literature review analysing endorsed performance and quality-in-care
measures for emergency department assessment
Christian Michel Sørup1*, Peter Jacobsen1, Jakob Lundager Forberg2
1
Management Engineering, Technical University of Denmark, Denmark; 2The
Emergency Department, Hillerød Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A12
Background: Evaluation of the performance of an emergency department
(ED) remains a difficult task due to the lack of consensus on performance
measures that reflects both high quality and efficiency. Hence, this study
describes, maps, and critically evaluates what performance measures that
the published literature regards as being most relevant in assessing overall
ED performance.
Methods: A systematic literature review in the databases of PubMed,
Cochrane Library, and Web of Science of articles on suggested ED
performance measures.
Results: A number of articles addressed this study’s objective (n = 14 of 46
unique hits). Time intervals and patient-related measures were dominant in
the recommendations made in studies from US, UK, Sweden and Canada.
Length of stay (LOS), time between patient arrival to initial clinical
assessment, and time between patient arrivals to admission are
recommended by the majority of studies. Concurrently, ‘patients left
without being seen’ (LWBS), unplanned re-attendance within a maximum
of 72 hours, mortality/morbidity, and number of unintended incidents
make out the most recommended performance measures related directly
to the patient. Performance measures related directly to employees were
only stated in two of the 14 included studies. Operational performance
measures are deemed covered for by the two clusters 1) time intervals and
2) patient-related performance measures.
Conclusion: 54 performance measures have been extracted from 14
studies. ED time intervals are the most recommended performance
measures followed by patient centeredness and safety performance
measures. ED employee related performance measures are rarely mentioned
in the investigated literature. Further work will include working towards
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
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consensus agreement on ED performance measures that preferably should
include several aspects of performance. Moreover, investigation of the
interconnectivity between the performance measures and how to measure
if launched initiatives have the wanted effects.
A13
A review of consecutive cardiac arrests in 2007 and 2012 at a regional
hospital in Denmark: a retrospective cohort study
Lisbeth Quitzau1*, Henriette Ullerup-Aagaard2, Mikkel Brabrand3
1
Department of Anesthesiology, Sygehus Lillebaelt, Kolding, Denmark;
2
Department of Cardiology, Sydvestjysk Sygehus Esbjerg, Denmark;
3
Department of Emergency Medicine, Sydvestjysk Sygehus Esbjerg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A13
Background: Not much is known about the fate of victims of cardiac
arrest (CA) in Denmark. We performed the present study to describe the
events surrounding CA at a regional hospital in Denmark.
Methods: Retrospective analysis of all consecutive CA at Sydvestjysk
Sygehus (SVS) in 2007 and 2012, i.e. two years after implementation of
new international resuscitation guidelines. The events were identified
using a registry in the Department of Anesthesiology. Using a unique
personal identification number, we retrieved the patient records and
extracted the relevant data.
Results: We identified 246 cardiac arrests; 154 out-of-hospital and 90 inhospital (and 2 unknown). 66% were male and the median age was 69 years
(range 11-99 years). 38% occurred during daytime, 33% during evenings
and 29% at night.
Over all, the primary cause was unknown in 85/246 (29%). There was a
decrease in CA caused by acute coronary syndrome (ACS) from 29/117
(25%) in 2007 to 19/129 (15%) in 2012, and an increase caused by
respiratory insufficiency from 18/117 (15%) in 2007 to 31/129 (24%) in 2012.
In 2007 83/117 (71%) presented with asystolia/PEA compared to 65/129
(50%) in 2012. The proportion of ventricular tachycardia/fibrillation
remained unchanged.
27/117 (23%) achieved return of spontaneous circulation (ROSC) in 2007
and 60/129 (47%) in 2012. 18/60 (30%) were discharged or transferred for
further treatment in 2012, in comparison to 14/27 (52%) in 2007.
Conclusion: Most CA at SVS occurred out-of hospital. The majority were
men and the median age was 69 years. They were evenly distributed
around the clock. The primary cause was mainly unknown but an increasing
number was caused by respiratory insufficiency and a decreasing number
by ACS. Asystolia as the presenting rhythm was decreasing. More patients
gained ROSC, but the proportion that were discharged or transferred to a
university hospital decreased.
A14
A study of local guidelines for use of an Early Warning Score System to
identify patients in need of treatment in the Intensive Care Unit
Jesper Kørup Jensen1*, Dorthe Hellemann2, Gustav From1
1
Emergency Department, Slagelse Sygehus, Denmark; 2Department of
Anesthesiology, Slagelse Sygehus, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A14
Background: Scientific studies suggests that transfer delays from the
Emergency Department(ED) to the Intensive Care Unit(ICU) increases
mortality and morbidity.
A modified Standardized Early Warning Scoring System called Basal
Observations Score(BOS) is used in Region Sjælland to monitor vital signs of
in-hospital patients. Respiratory rate, peripheral O2-saturation, systolic blood
pressure, heart rate, Glasgow Coma Scale, and urinary output are included.
BOS is documented on special paper forms, and on electronic white boards.
The clinical guidelines for the ED states that patients with BOS>5 should
preferably be treated in the ICU.
The aim with this study was to evaluate the guidelines and the accordance
between guidelines, and clinical practice.
Page 5 of 17
Methods: A retrospective cohort study was conducted, including all
patients admitted to the ED with BOS≥5 on the electronic white board,
from 1/5 to 16/10 2012. All journal entries from the ED were audited in
order to validate BOS, and carry out a descriptive analysis of specified
endpoints.
Results: 134 patients were included. 15 of these were not considered
candidates for ICU admission by ED clinicians. 89 had BOS>5. There was
no significant difference between the mortality (p>0,25), length of
admission (p=0,134), or proportion of transfers to ICU between BOS=5
and BOS>5 (p>0,5).
15 patients were assessed by anesthesiologists (12,6%, 95%CI=6,64-18,57).
11 of these were transferred to the ICU (73,33%, 95%CI=50,95-95,71). The
average length of stay in the ED was 237 minutes (95%CI=88-386).
Conclusion: Fewer requests, for assessment by an anesthesiologist, were
made than expected. Once assessed, the majority of patients were
transferred to the ICU, suggesting that clinical practice in the ED was not
in compliance with guidelines. Further studies are needed to clarify how
the use of an anesthesiologist to optimize treatment, and evaluate
transfer to ICU, is implemented.
Patients transferred to the ICU spent an average of almost 4 hours in the ED.
There was no difference between endpoints between patients with BOS=5
and BOS>5, and no significant difference in the time spent in the ED
between the two groups. The conclusion is that these groups should be
considered equal candidates for ICU admission in the clinical guidelines.
A15
A third of all abstracts from the 2009 and 2010 Danish Emergency
Medicine Conferences have been published as full-text articles: a
retrospective study
Mikkel Brabrand1,2*, Dan Brun Petersen1, Lars Folkestad1,3, Peter Hallas1
1
Danish Society for Emergency Medicine, Denmark; 2Department of
Medicine, Sydvestjysk Sygehus Esbjerg, Denmark; 3Department of
Endocrinology, Sydvestjysk Sygehus Esbjerg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A15
Background: Many authors initially present study data as an abstract at a
medical conference. Later on, after initial presentation, the study should
ideally be presented as a full-text article in a peer-reviewed journal,
regardless if the findings were positive or negative. Previous studies have
shown that approximately a third of abstracts presented at Emergency
Medicine conferences are published as peer-reviewed articles. We set out to
establish the proportion of abstracts presented at the Danish Emergency
Medicine Conferences (DEMC) in 2009 and 2010 that were published as
articles in peer-reviewed journals.
Methods: This is a retrospective study using the lists of accepted
abstracts from the 2009 and 2010 DEMC published in the Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine. As a sub
analysis, we included the abstracts from the 2011 DEMC, but as this was
held less than 18 months ago, we excluded the numbers from analyses.
We manually searched PubMed using the names of the authors and
extracts of the titles of the abstracts up to January 2013. Data will be
presented descriptively and differences between proportions tested using
Chi-square test.
Results: From the 2009 DEMC, 19 abstracts were published. Of these, six
(31.6 %) had been published as full-text articles in peer-reviewed journals.
As for the 2010 DEMC, 44 abstracts were published from the conference and
12 (27.3 %) of these had been published as full-text articles, p = 0.73. Six of
all the published abstracts had been presented as oral presentation, and
four of these (66.7 %) had been published while 14 (24.6 %) of the 57
abstracts presented as poster presentations had been published as full-text
articles, p = 0.03. From the 2011 DEMC, 55 abstracts were published and six
(10.9 %, none of which were oral presentations) have later been published
as full-text peer-reviewed articles.
Conclusion: Approximately one-third of abstracts published from the
2009 and 2010 Danish Emergency Medicine Conferences have been
published as full-text articles in peer-reviewed journals by January 2013.
Significantly more abstracts presented as oral presentations have been
published. These numbers are similar to larger international Emergency
Medicine conferences.
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
A16
Acute Coronary Syndrome revisited
Niels Christian Kromann*, Anne Grethe Mølbak, Jacob Hansen-Schwartz
Emergency Dept., Køge Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A16
Background: Chest pain is an indicator of possible myocardial infarction.
Definite diagnosis of non ST-elevation myocardial infarction (NSTEMI)
requires sequential measurement of troponin levels. It is a challenge for the
Emergency Department physician to select patients for observation. The aim
of the present study was retrospectively to describe the patient cohort
selected for observation with an extended focus on patients having the
diagnosis confirmed.
Methods: Patients admitted for observation for myocardial infarction at
Køge Hospital in the period July to December 2012 were identified through
“Landspatientregistret”. 273 consecutively admitted patients were identified.
Parameters recorded: Age, gender, date of admittance, and troponin
levels. For patients with elevated troponin levels the following parameters
were identified: Risk factors such as hypertension, diabetes mellitus,
hypercholesterolemia, smoking, genetic disposition, and history of
ischemic heart disease. Presence of novel ischemic ECG changes was
registered as well as flow limiting lesions observed on performing
coronary arteriography (CAG).
Results: 36 patients (13%) had NSTEMI confirmed. Mean age at time of
admittance was 70 years (range 44 to 95 years). M:F gender distribution
was 56:44. In comparison, mean age of patients not harbouring
myocardial infarction was 63 years (range 27 to 96 years) with a gender
distribution of 43:57. The age difference was statistically significant
(p<0.05).
19 patients (53%) had two or more risk factors. Nine patients (25%) had
ischemic ECG changes. 27 patients (75%) had CAG performed, of these
21 were pathological.
Conclusion: Absence of ischemic ECG changes at the time of admittance is
not a good predictor of a non-ischemic event. Presence of ischemic risk
factors at the time of admittance increases the likelihood of an ischemic
event. Absence of risk factors is an invalid predictor of non-ischemic events.
The proportion of patients with non-ischemic chest pain is a differential
diagnostic problem. Through further stratification it is the intention to take
into account patients with unstable angina.
A17
An alternative resuscitation algorithm significantly reduces hands-of
time during CPR: a full-scale simulation study
Magnus Pedersen1*, Anna Mohammed1, Lars Folkestad2, Jacob Brodersen3,
Mikkel Brabrand1
1
Department of Medicine, Sydvestjysk Sygehus Esbjerg, Denmark;
2
Department of Endocrinology, Sydvestjysk Sygehus Esbjerg, Denmark;
3
Department of Gastroenterology, Sydvestjysk Sygehus Esbjerg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A17
Background: A reduction in hands-off time during resuscitation leads to
increased survival. We have previously shown that hands-off time can be
reduced using our alternative cardio-pulmonary resuscitation (CPR)
algorithm SOWS (Stop Only While Shocking), but only in small and limited
simulations. We designed the present study to compare SOWS to the
current European Resuscitation Council (ERC) 2010 guidelines in full-scale
simulations. The aim was to decrease hands-off time.
Methods: Using a randomized design, we compared SOWS to the 2010 ERC
guidelines using predefined scenarios. In our algorithm, the defibrillator was
charged while CPR was ongoing and compressions only interrupted for
rhythm check. If a shock was required, it was delivered immediately and
compressions resumed. A Laerdal Resusci® Anne and Lifepak 20 defibrillator
were used. Hands-off time in percent of the entire cardiac arrest and
compressions per minute were registered. Data will be presented as mean
(standard deviation [SD]). Differences were tested using unpaired students
t-test.
Page 6 of 17
Results: Thirty physicians participated (they had participated in 12-21
cardiac arrests and nine had completed an ALS course). We performed 11
full-scale simulations, six using 2010 ERC guidelines and five using SOWS.
Mean hands-off time using ERC guidelines was 26.7 % (SD 4.3%) and 22.1
% (SD 2.3%) using SOWS, p = 0.02. Using ERC 2010 guidelines resulted in
mean 83.8 (SD 13.7) compressions per minute and 95.0 (SD 2.4)
compressions per minute with SOWS, p = 0.18.
Conclusion: Using full-scale simulations, we demonstrated a significantly
lower hands-off time when comparing SOWS to the 2010 ERC guidelines.
Furthermore, an increase in compressions per minute where registered
with our alternative algorithm, but this was not significant.
A18
Application of Structural Equation Modeling to determine Emergency
Department patient satisfaction drivers
Christian Michel Sørup*, Peter Jacobsen
DTU Management Engineering, Technical University of Denmark, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A18
Background: Diverse theories concerning what emergency department
(ED) patients appreciate the most remains a fact despite heavy academic
interest during the last decade. Four hypotheses of theoretically
grounded causal effects between the latent (unobserved) variables wait
time, information delivery, infrastructure and safety are tested by the use
of structural equation modeling (SEM).
Methods: The empirical material is provided by the Unit of PatientPerceived Quality through a recently published telephone survey. The
responses were clustered in categories through an exploratory factor
analysis and assessed for construct validity (Cronbach’s alpha). The five
hypotheses were analysed further by the use of a two-step structural
equation modeling approach as prescribed by Anderson and Gerbing in
1988. First step involves a confirmatory factor analysis to assess validity of a
base line model (measurement model) and ensures that the constructs are
distinct from each other (discriminant validity). Second step is the alteration
of the measurement model into a structural model, which allows for testing
of the constructs’ interconnections.
Results: Two structural models were evaluated for best data fit. The final
retained structural model did not dismiss any of the four hypotheses. All
path coefficients were statistically significant at a minimum a = 0.05
level, with a single exception.
Conclusion: Application of SEM on comprehensive empirical data permits
clarity of where to target future efforts to improve ED operations.
Furthermore, SEM allows for measurement error adjustments and
simultaneous estimation of all included parameters. This study manages to
extract valuable information in a comprehensive data sample enabled by
the application of a mathematically acknowledged modeling technique.
Hence, the findings may serve as endorsements for improved ED patient
satisfaction rates.
A19
Bacteremic patients in the Emergency Department – how do they
present and what is the diagnostic validity of temperature,
CRP and SIRS?
Katrine Prier Lindvig1*, Stig Lønberg Nielsen2, Daniel Henriksen1,
Thøger Gorm Jensen3, Hans Jørn Kolmos3, Court Pedersen2,
Annmarie Touborg Lassen1
1
Department of Emergency Medicine Odense University Hospital, Denmark;
2
Department of Infectious Diseases Odense University Hospital, Denmark;
3
Department of Clinical Microbiology Odense University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A19
Background: It might be a clinical challenge to identify patients with
bacteremia. Blood cultures are often ordered based on the symptoms of
fever and chills. Detailed knowledge of the clinical presentation of acute
medical patients will improve the identification of bacteremic patients.
The aim of this study was to evaluate the diagnostic value of
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
temperature (°C), C-reactive-protein (CRP), and Systemic Inflammatory
Response Syndrome (SIRS) in bacteremic patients admitted to the
Medical Emergency Department (ED).
Methods: A population based cohort study including all adult (>15 years
old) first-time admissions at the ED at Odense University Hospital
between 1/8 2009-31/8 2011. A bacteremic patient was defined as having
a positive blood culture drawn within the first two days after admission.
All patients had their bloodpressure, pulse rate, respiratory frequency,
oxygen saturation, level of consciousness measured and standard blood
samples drawn at arrival.
Results: We included 11.996 acute medical patients and excluded 31
patients because of missing identification data. Median age was 66 years
(range 15-103), and 5499 (45.0%) were male. In total 5503 (45.9%) patients
had blood cultures performed, of which 418 (7.6%) were culture positive,
defining bacteremia. Of the 418 bacteremic patients, 381 had a temperature
measured at arrival; hereof 130 (34.1%) patients had a normal rectal
temperature (36.0°-38.0°C) registered, 116 (28 %) had a CRP<100mg/dL, and
102 (24%) did not fulfil the criteria for SIRS. The most frequent species
among the 130 patients with normal temperature were E.coli n=39 (30%),
S. aureus n=19 (15%) and S.pneumoniae n=13 (10%). The ROC-area for CRP
and temperature as predictors of bacteraemia were 0.67 and 0.75
respectively, representing a sensitivity of 0.66 and a specificity of 0.82 with a
CPR-cut-off-value of 100, and a sensitivity of 0.59 and a specificity of 0.84
with a temperature-cut-off-value of ≥38.0°C.
Conclusion: 34% of the acute medical bacteremic patients had a normal
temperature when arriving at the hospital, 32% had a CRP below 100 mg/dL
and 24% did not fulfil the criteria for SIRS. If the decision to order blood
cultures were based on either temperature, CRP or SIRS, one third of all
bacteremic patients would have been overlooked.
A20
Capillary refill time is a poor predictor of 30-day mortality: an
observational cohort study
Monija Mrgan1*, Dorte Rytter2, Mikkel Brabrand1
1
Department of Cardiology, Sydvestjysk Sygehus, Finsensgade 35, 6700
Esbjerg, Denmark; 2Department of Medicine, Sygehus Lillebælt,
Dronningensgade 97, 7000 Fredericia, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A20
Background: Capillary refill time (CRT) was introduced in 1947. In the
1980`s, it was proposed as one of five elements in the Trauma Score and
defined as two seconds or less in all adult patients. An alternative definition
(sex and age dependent) has been introduced by Schriger and Baraff.
We performed a prospective observational cohort study to assess the
relationship between CRT and 30-day mortality.
Methods: The study originates from the medical admission unit at
Sydvestjysk Sygehus, Esbjerg from 2 October 2008 to 19 February 2009. All
acutely admitted adult patients (age 15 and older)were included and the
nurse recorded and reported the vital signs (including CRT). The primary
outcome was 30-day all-cause mortality. To ensure complete follow-up, data
on the endpoint was extracted from the Danish Person Register. Difference
between continuous data was analyzed using Wilcoxon Rank Sum Test and
categorical data were compared using chi-squared test. We performed
multivariable logistic regressions to identify CRT as an independent
predictors of 30-day mortality controlling for other vital signs, sex and age.
Results: A total of 3,046 patients were enrolled and CRT was measured on
1,935 (63.5 %). Patients with a CRT ≤ 1 had a 30-day mortality of 3.8 %
compared to patients with a CRT ≥ 5 (18.2 %). Patients with an abnormal
CRT according to the Trauma Score had a 30-day mortality of 8.6 % versus
5 % (p = 0.002). Abnormal CRT according to the Schriger and Baraff’s
definition resulted in a 30-day mortality of 5.5 % versus 6.3 % (p = 0.51).
Logistic regression showed CRT not to be an independent predictor of
30-day mortality, neither as a continuous variable, nor by either definition.
Conclusion: CRT is associated with mortality, however, we were only able
to show this in univariable analyses and only for the Trauma Score
definition. When performing multivariable logistic regression controlling for
the other vital signs, we were unable to show any association.
Our data show that CRT is a poor vital sign and we discourage use in the
clinical setting.
Page 7 of 17
A21
Diagnostic performance of chest X-ray for the diagnosis of community
acquired pneumonia in acute admitted patients with respiratory
symptoms
Christian B Laursen1*, Erik Sloth2, Jess Lambrechtsen3,
Annmarie Touborg Lassen4, Poul Henning Madsen5,
Daniel Pilsgaard Henriksen4, Jesper Rømhild Davidsen1, Finn Rasmussen6
1
Department of Respiratory Medicine, Odense University Hospital, Denmark;
2
Department of Anaesthesia and Intensive Care, Aarhus University Hospital,
Skejby, Denmark; 3Department of Medicine, Odense University Hospital Svendborg, Denmark; 4Medical Emergency Department, Odense University
Hospital, Denmark; 5Department of Medicine, Sygehus Lillebælt, Denmark;
6
Department of Allergy and Respiratory Medicine, Near East University
Hospital, Nicosia. North Cyprus, Mersin 10, Turkey
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A21
Background: Despite being a routine diagnostic modality for the
diagnosis of community acquired pneumonia (CAP), few studies have
evaluated the diagnostic performance for the diagnosis of CAP according
to an initial performed chest x-ray (CXR) in an emergency department
(ED). As a part of a prospective observational study of patients admitted
with acute respiratory symptoms in an ED, this relation was evaluated.
Methods: A prospective cross sectional observational study was
conducted in a medical ED. Patients were included if one or more of the
following clinical findings or symptoms were present: respiratory rate >
20/minute, oxygen saturation < 95 %, oxygen therapy initiated, dyspnoea,
cough, or chest pain. The assessments of the CXR by the treating
physician in the ED and the radiologist were prospectively registered.
Blinded audit by three physicians who used predefined diagnostic criteria
was used as gold standard.
Results: 342 patients were screened of whom 139 (40.6%) were included.
An acute CXR was performed in 121 (87.1%) of the patients. In 50 (41.3%)
of the patients, the treating physician in the ED described the CXR with
opacity due to CAP. The radiologist described opacity due to CAP in 54
(44.3%) of the cases. Audit found 58 (47.9%) of the patients met the
predefined criteria for CAP. Diagnostic performance of the CXR evaluated
by the treating physician was: sensitivity 70.7% (95%CI 57.3-81.9%),
specificity 85.7% (95%CI 74.6-93.3%), PPV 82.0% (95%CI 68.6-91.4%), NPV
76.1% (95%CI 64-5-85.4%) and ROC area 0.782 (95%CI 0.709-0.855%).
Diagnostic performance of the initial CXR evaluated by a radiologist was:
sensitivity 69.0% (95%CI 55.5-80.5%), specificity 77.8% (95% CI 65.587.3%), PPV 74.1% (95%CI 60.3-85.0%), NPV 73.1% (95%CI 60.9-83.2%),
and ROC area 0.734 (95%CI 0.654-0.813). The overall agreement between
the treating physician and radiologist was 71.4% (ê 0.429).
Conclusion: Based on these findings, the initial CXR will only be able to
diagnose seven out of ten patients with CAP in patients with respiratory
symptoms who are acutely admitted to a medical ED. In accordance with
Fleiss’ guidelines, the agreement between treating physician and
radiologist for the assessment of chest x-ray for the diagnosis of CAP is
fair to good.
A22
Does hyperlactatemia at admission predict mortality in acute medical
patients? A population based cohort study
Felix Haidl1*, Daniel Pilsgaard Henriksen2, Mikkel Brabrand3, Annmarie Lassen2
1
Department of Anesthesia, Sygehus Lillebælt, Kolding, Denmark;
2
Emergency Department, Odense University Hospital, Odense, Denmark;
3
Department of Medicine, Sydvestjysk Sygehus, Esbjerg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A22
Background: An increased lactate level is related to elevated mortality in
various subpopulations of critically ill patients, e.g. sepsis and trauma. The
aim of the present study was to investigate to which degree lactate is
related to increased mortality in a broad cohort of acute medical patients.
Methods: Single centre cohort study. All adult patients admitted to the
medical emergency ward of Odense University Hospital from March 2009
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
to August 2011, who had an arterial blood gas sample taken within six
hours after admission were enrolled. Lactate was stratified in 1mmol/l
(mM) intervals. Ten-day mortality after admission was assessed through
the Danish Centralised Civil Registration system. A further stratification
according to systolic hypotension (< 90 mmHg) was performed. Finally, a
survival analysis (Kaplan-Meyer plot) was performed for the first ten days.
Results: 5,318 patients were enrolled, 2,493 male, median age 71 years
(5% and 95% inter quartiles 25-91 years). Median lactate level was 1.2 mM
(5% and 95% interquartile range 0.6-3.8 mM). Ten-day mortality was 382/
5,318 (7.2 %). Ten-day mortality increased with increasing lactate at arrival
with 79/1,778 (4.2 %) for lactate 0-0.99 mM, 132/2,182 (5.7 %) for lactate
1.0-1.9 mM, 71/614 (10.3 %) for lactate 2,0-2,9 mM, 29/174 (14.3 %) for
lactate 3.0-3.9 mM, 23/87 (20.9 %) for lactate 4.0-4.9 mM, 6/42 (12.5 %)
for lactate 5.0-5.9 mM, 10/18 (35.7 %) for lactate 6.0-6.9 mM, 7/11 (38.9 %)
for lactate 7.0-7.9 mM and 25/30 (45.5 %) for lactate ≥ 8 mM (Cuzick’s test
for trend, p < 0.001). This pattern was more marked in the hypotensive
subpopulation. Survival analysis indicated that the increase in mortality
was most pronounced within the first five days.
Conclusion: Lactate levels drawn within six hours of admission is a
predictor of mortality among patients admitted to the acute medical
ward. Mortality is increased with each mM of lactate increase.
A23
Effect of a pocket size guideline book in the emergency department; a
questionnaire study
Melanie Correia Schrøder*, Dan Brun Petersen
Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A23
Background: Traditionally Danish clinical guidelines cover specific
diagnoses. However these guidelines are not always suitable for the acute
patients presenting at the Emergency Department (ED). In 2009 the ED at
Kolding Hospital developed a pocket size guideline book containing the
conditions most commonly encountered in the ED. At Holbaek University
Hospital guidelines are developed by each specialty and are only available
online at the hospital intranet. We wished to investigate the effect of a
pocket size guideline book.
Methods: A questionnaire was sent to all junior doctors at the two EDs
asking how easy it was to find the guidelines. Each question should be
answered on 41 different subjects, mostly clinical but also administrative.
Results: Almost all doctors from Kolding answered ”easy” or ”very easy”
to finding most of the guidelines, but the return rate was only 7 out of
22 (32%), and consequently no comparison could be made.
The return rate from Holbaek was 11 out of 15 (73%). All answered “easy”
to finding some guidelines and “difficult” to finding others, rendering no
clear conclusion.
The majority answered that it is “easy” or “very easy” to find guidelines for
Cardiac arrest (11/11), DVT (10/11) and Triage (10/11). On the contrary, it is
”difficult” or ”very difficult” to find guidelines for ECG (8/11), Involuntary
Treatment of Psychiatric Patients (8/11), Fluid & Electrolyte treatment (7/11),
and Pain Management (7/11).
One respondent commented: ”Information is easily found on the internet –
not on the local intranet because of its inadequate search function”.
Conclusion: We could not compare the two departments. However there
is a great difference in how easily doctors can retrieve guidelines, which
jeopardizes the use of the valid, local guidelines. Certain subjects need
more attention than others.
A pocket size guideline book will be introduced in Holbaek in the spring of
2013. All junior doctors rotate out of the department every semester, thus
after the next rotation we will repeat the questionnaire in order to investigate
if the new group of doctors experience easier access to the local guidelines.
A24
Emergency department patients with suspected infection at risk of
intensive care unit transfer: a case-control Study
Marie K Jessen Pedersen1,2*, Julie Mackenhauer1,2,3, Anne Mette S W Hvass2,4,
Hans Kirkegaard1,2,5
1
Research Center for Emergency Medicine, Aarhus University Hospital,
Denmark; 2CONSIDER Sepsis Network, Denmark; 3Emergency Department,
Regional Hospital, Hjørring, Denmark; 4Department of Infectious Disease,
Page 8 of 17
Aarhus University Hospital, Denmark; 5Department of Anaesthesiology and
Intensive Care, Aarhus University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A24
Background: Sepsis is a time critical diagnosis and early treatment in the
Emergency Department (ED) is essential. A challenge faced by emergency
physicians is determining which patients with suspected infection will
deteriorate and should be admitted to an intensive care unit (ICU). The aim
of this study is to describe the population of ED patients with suspected
infection. Further to compare patients who die or are transferred to an ICU
within 2 days to those remaining at primary wards.
Methods: We performed a retrospective case-control study. Inclusion
criteria were: age>18y having a blood culture drawn upon admission to the
ED at Aarhus University Hospital (MVA, KVA or Skadestuen) Jan 1st-Dec 31st
2011. Patients were grouped by in-hospital course within the first 2 days.
Cases had a combined endpoint of death or ICU-transfer within 2 days.
Controls remained at primary wards or in the ED. Matching was 1:3 by age
and admission month. Laboratory results, antibiotics and clinical data were
collected. Odds ratio (OR) and 95% confidence interval [CI] were calculated.
Results: Of 1578 patients, 140 cases were matched to 401 controls. Total inhospital mortality was 9%. Predictors of ICU-transfer or death within 2 days
included lactate>2.5 mmol/L (OR 11.78 [6.93-20.4]), creatinine>170mmol/L
(OR 4.28 [2.50-7.32]), respiratory rate>20min-1 (OR 3.71 [2.38-5.77]), altered
mental status (OR 5.87 [3.69-9.34]) and having a suspected infection with
unknown focus upon arrival (OR 2.13 [1.42-3.20]). Having more than one inhospital ward transfer within 48 hours increased the risk of ICU-transfer or
death (OR 2.09 [1.34-3.28]). Cases were more likely to fulfill the SIRS criterias
compared to controls: Heart rate 105min-1[82;125] vs. 92min-1[80;105],
respiratory rate 25min-1[17;32] vs.18min-1[15;24], WBC 12.9[9.3;19.9] vs. 10.8
[7.8;14.5] while median temperature was normal both for cases 37.7°C
[36.8;38.5] and controls 37.9°C[37.1;38.6].
Conclusion: Simple clinical and paraclinical variables in the ED can predict
outcome within two days. Having more than one in-hospital ward transfer
seems to influence patient outcome negatively. Fever was not present for
the majority of both cases and controls questioning the value of initial
temperature as a predictor of severe outcome. Further analysis is needed
developing a prediction rule of death or ICU-transfer within 2 days.
A25
Emergency departments in Denmark with a research responsible
consultant expect increased research production
Cecilie Markvard Møller1,2*, Julie Mackenhauer1, Anders Brøns Møllekær1,
Mikkel Brabrand3, Peter Hallas4, Hans Kirkegaard1
1
Research Center for Emergency Medicine, Aarhus University, Denmark;
2
Department of Internal Medicine, Regionshospitalet Viborg, Denmark;
3
Department of Medicine, Sydvestjysk Sygehus Esbjerg, Denmark;
4
Department of Anesthesia, JMC, Rigshospitalet, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A25
Background: Emergency medicine (EM) is not a recognized specialty in
Denmark, but an area of competence. In Denmark this is new, and current
research production in the Emergency departments (EDs) is limited. As in
other areas of clinical medicine, there is a need for research to ensure high
quality evidence-based patient care.
The aim of our study was to examine 1) the current research activity in the
Danish EDs, 2) the impact of having a research responsible consultant on
scientific production, 3) the relationship between production and opinion
of the head of department with regards to EM as an area of competence
respectively a specialty.
Methods: A survey was conducted among the 21 ED department heads.
Data was collected during September 2012. The respondents were asked for
1) number of publications in 2011, 2) number of expected publications in
2012, 3) whether the department had a research responsible consultant and
4) whether the respondent thought an EM specialty compared to an area of
competence would increase research activity.
Results: Answers were obtained from all 21 EDs. In 2011, 48% (n=10) did
not publish any scientific papers while the rest published 1-10 papers. In
2012, 24% (n=5) of the departments did not expect any publications (none
have a research responsible consultant) and 57% (n=12) expect 1-10
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
publications (83% (n=10) have a research responsible consultant). Only one
department anticipated more than 10 publications.
52% (n=11) of the departments have a research responsible consultant
and they expect an increased scientific production the impending year, in
fact these departments all expected publications, while only 20% of the
departments without such consultant expected publications (p<0,01,
Fisher’s Exact test).
62% (n=13) of the department heads agreed in varying degree that an
EM specialty compared to an area of competence would increase
research activity, while 14% (n=3) disagreed.
Conclusion: Research activity in the Danish EDs is limited but expected
to increase - more in departments with a research responsible consultant
than in EDs without. There is a general believe that establishment of an
EM specialty will increase research activity.
A26
Evaluating the impact of electronic whiteboard icons: an observational
study of the work with blood tests in an emergency department
Arnvør á Torkilsheyggi1*, Morten Hertzum1, Gustav From2
1
Computer Science and Informatics, Roskilde University, Roskilde, Denmark;
2
Emergency Department, Slagelse Hospital, Slagelse, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A26
Background: Results of blood test are essential and often guiding for the
diagnostic work. In emergency departments (EDs) a competent and rapid
treatment therefore requires an efficient process for ordering blood tests,
informing clinicians that samples have been taken, for communicating
test results, and for physicians acknowledging having assessed results.
The ED in Slagelse Sygehus has implemented icons on their electronic
whiteboard that visualize the progress of the blood-test process.
The aim of our study was to evaluate the impact of the icons on the
workflow.
Methods: The study was designed as a qualitative study using the
methods of observations and informal interviews.
The observations amounted to 19 hours in total and consisted of
shadowing 6 physicians and 2 nurses for a couple of hours at a time.
Informal individual interviews were held with all observed professionals
and with another two nurses, two laboratory technicians, a coordination
nurse, a triage nurse, and a secretary.
Results: The nurses frequently attended to the icons on the whiteboard.
The arrival of new test results was seen as an opportunity to make the
physicians aware of patients that could be discharged or transferred to
other departments. The icons thereby supported the nurses in
maintaining flow of patients.
The physicians did not attend to the icons for maintaining flow, but used
the icons at two daily timeouts, when they collectively assessed patients.
Overall they considered test results as input to the clinical evaluation of
individual patients.
Conclusion: Our study indicates that the blood-test process can
contribute to the steering of which patient the physicians should see
next. Presently, this steering is mediated by nurses, who keep an eye out
for the icons reflecting the blood-test process.
The physicians did not attend the icons themselves, hence the blood-test
process did not steer physicians directly. If the blood-test process should
steer physicians’ actions directly, bypassing the nurses, the information of
blood tests should be mediated by other means, for example by
smartphones carried by the physicians. This calls for further studies.
A27
Health care quality in a new Emergency Department based on the
Danish Stroke register data
Maria Søe Mattsson*, Michael Oettinger, Hanne Jørsboe
Emergency Department, Nykøbing F. hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A27
Background: One of the intentions to develop the concept of an ED in
Denmark is to increase health care quality in the treatment of acute
patients. However, it is a massive reorganization including other
Page 9 of 17
workflows and competency profiles. At present, there are not established
any general quality indicators for the acute treatment, but hospitals have
reported to the Danish Stroke Register (DAP) for selected diseases. We
have chosen “Stroke” as case to evaluate quality during a 3 years period
under implementation of the ED concept, since these patients are among
the 20 most common illnesses in our department.
Methods: The study is quasi-experimental. All patients with Stroke from the
ED at Nykøbing F. Hospital, which reported to DAP since 2007, are included
in the study. Period 2007/2008 works as a historical control. The ED started
at April 2009. In the study, indicators are chosen to describe early
interventions in the patient pathway and compare them with nationwide
data. Data is processed in STATA and Chi2-test is used to analyze whether
there has been a change over time.
Results: 1715 patients entered the study. Gender and age are comparable.
Analysis shows that concerning the indicator CT/MR scan within 24 hours,
there has been a improvement both in the ED (50% in 2007/2008, 55% in
2009, 65% 2010, 76% in 2011, 83% in 2012, p < 0,005) and nationally (67%
in 2007/2008 to 85% in 2011). Similarly, the indicator concerning treatment
with antiplatelet therapy, improvement are made in both the ED (50% in
2007/2008, 55% in 2009, 65% 2010, 76% in 2011, 83% in 2012, p < 0,005)
and nationally (87% in 2007/2008 to 93% in 2011). Relative to mortality
within 30 days, there has been an improvement in the ED (13% in 2007/
2008, 9% in 2009, 11% 2010, 8% in 2011, 5% in 2012, p < 0,005) but not
nationally (10% in 2007/2008 to 11% in 2011).
Conclusion: During establishment of an ED, the treatment of stroke has
improved reflecting earlier diagnosis and treatment. The results are
comparable to nationwide results from other organisational setup. It is
recommended, that indicators for monitoring acute treatment in Denmark
is developed.
A28
How well does TOKS identify patients with severe sepsis or septic
shock?
Anette Tanderup1*, Merete Storgaard2, Annmarie Lassen3
1
Department of Geriatric, Odense University Hospital, Denmark; 2Department
of Infectious Medicine, Aarhus University, Denmark; 3Department of
Emergency Medicine, Odense University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A28
Background: Several scoring system have been developed with the aim
to identify clinical deterioration among hospitalized patients and allocate
resources in accordance with the degree of deterioration - most without
validation. The aim of the present study was to describe to which degree
the system “Tidlig Opsporing af Kritisk Sygdom” (TOKS) is able to identify
patients who either have or develop severe sepsis or septic shock within
24 after arrival to hospital.
Methods: A retrospective descriptive study of patients hospitalized with
community acquired severe sepsis or septic shock. Patients were
identified based at discharge diagnosis ((IDC10 code A40.0-A41.9). Based
at a manual evaluation of all patient records patients were included if
they within the first 24 hours after arrival to the hospital fulfilled
predefined criteria for severe sepsis or septic shock. Vital values
registered at arrival to the hospital were identified and used for the
present analysis. TOKS score is based at scores for respiratory frequency,
saturation, systolic blood pressure, pulse rate, consciousness and
temperature. The score range from 0 to 21 with an indication of need for
a doctoral evaluation if the score is 3 or higher.
Results: 335 patients were discharged with a diagnosis of sepsis. 212
fulfilled the criteria for severe sepsis or septic shock within the first
24 hours of hospitalization. One hundred and six (50%) were male, mean
age 70.6 years (SD 14.7, range 24.0-96.6 years), 103 (49%) had septic
shock. Median TOKS score at arrival was 4 (range 0-13). 10/212 (5%) had
TOKS=0, indicating no need for measurements of vital values the next
24 hours, 20/212 (9%) had TOKS=1, indicating measurements of vital
values every 8 hours, 13/212 (6%) had TOKS=2 indicating control of vital
values after one hour, 66/212(31%) had TOKS 3-4 indicating need for
evaluation by a junior doctor and 103/121 (49%) had a TOKS score≥5
indicating need for urgent specialist evaluation.
Conclusion: 14% of the patients who develop severe sepsis or septic
shock within 24 hours after arrival to the hospital had a TOKS score at
arrival indicating a need for control of vital values every 8 hours or less.
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
A29
I see you? - Predicting who will require intensive care
Maria Bjørn Marcussen*, Christian Backer Mogensen
OUH Odense, Sygehus Lillebælt, Kolding, Region of Southern Denmark,
Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A29
Background: Delayed transfer to the intensive care unit (ICU) is
correlated with higher morbidity and mortality in emergency department
(ED) patients. If it is possible to identify patients at risk of transfer to the
ICU shortly after arrival to the ED, early goal-directed therapy could
theoretically reduce the incidence of ICU transfer and improve outcome
for the critically ill. No widely used scoring system exists for identifying
these patients in the heterogeneous population of the ED. The aim of
this study was to identify possible predictors obtainable on admission for
ICU therapy.
Methods: We conducted a retrospective case-control study with a total
of 10.000 acute patients. The case group consisted of adult patients,
transferred to the ICU between 3 and 36 hours after arrival, whom had
blood gas analysis done. The specialty-matched control group consisted of
adult patients who had blood gas analysis done but were not transferred to
the ICU. A total of 325 patients, 125 cases and 250 controls, were compared
with regards to vital parameters, age, gender, blood gas parameters, GCS,
Charlson comorbidity index, tobacco- and alcoholconsumption and number
of prescription drugs. We performed uni- and multivariate regression
analyses to identify risk factors associated with later ICU transfer. A p-value
below 0.05 was considered statistically significant.
Results: We found age between 60 and 80 years (OR 3.2), systolic blood
pressure below 90 or diastolic blood pressure below 50 (OR 3.7), oxygen
saturation below 90 (OR 3.2), temperature below 36 (OR 4.1), Charlson
score more than 0 (OR 3.1), lactate above 4 (OR 5.3), pH below 7.35 (OR
8.4) and pCO2 above 6.3 (OR 5.4) on admission to be significantly
associated with later ICU transfer. At multivariate analysis a pH value less
than 7.36 (OR 14.4), oxygen saturation below 90 and low blood pressure
(OR 4.4) remained significantly associated with ICU transfer.
Conclusion: These parameters can be used as part of ED triage identifying
high-risk patients who could benefit from early anesthesiologist consult,
early goal directed therapy or simply closer observation.
A30
Impaired comprehension of diagnostic procedures and medication
instructions in a quick diagnostic unit setting
Lisa Nebelin Hvidt1*, Kim Madsen1, Kristian Nebelin Hvidt2,
Thomas A Schmidt1
1
Department of Emergency Medicine, Holbaek University Hospital, Denmark;
2
Department of Medicine, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A30
Background: The Quick Diagnostic Unit (QDU) is an integrated part of
the Emergency Department and patients admitted are expected to have
a brief hospitalization. Understanding the discharge instructions is
essential for patients’ compliance. The objective of this study was to
investigate comprehension of discharge instructions among elderly
patients admitted to the QDU.
Methods: A total of 102 adult patients discharged from the QDU
answered a questionnaire covering self-assessed comprehension of
discharge information, ability to recall discharge information and
evaluation of the communication. Questions addressed diagnosis,
diagnostic procedures, treatment, follow-up and return instructions.
Answers from the questionnaire were compared with the discharge letter
and the degree of concordance was evaluated. Patient awareness of own
comprehension deficits was evaluated comparing self-assessed
comprehension with the ability to recall a correct answer. The population
was divided into two groups, an elderly group (age ≥ 65 years) and a
younger group.
Page 10 of 17
Results: Forty patients were allocated to the elderly group and sixty-two
to the younger group. The elderly group had more prior admissions
compared to the younger group (P=0.027), whereas no difference was
found for gender, education, other diseases or length of admission.
Admission diagnosis in the total population was mainly anaemia,
infectious or musculoskeletal disease. The range of self-assessed comprehension was 87.9 to 100% for the numerous conditions with no
differences between the two groups. When compared with the discharge
document the elderly group was less able to recall correct diagnostic
procedures (91.94% vs. 71.79%, P=0.007) and medication instructions
(77.97% vs. 54.29%, P=0.016). Furthermore, the elderly patients were less
aware of their own comprehension deficits regarding diagnostic tests
(P=0.006 / OR 0.95, 95% CI: 0.913-0.989, P=0.0115), preventive measures
(P=0.015), medication instructions (P=0.028 / OR 0.95, 95% CI: 0.921 to
0.980, P=0.001) and when to seek emergency care (0.041).
Conclusion: Elderly patients showed less ability to recall correct
diagnostic procedures and medication instructions compared to younger
patients. Furthermore they were less aware of their comprehension
deficits. In this perspective, communicating with elderly patients requires
special attention, this could involve “closed loops”, repetition or follow up
at a general practitioner.
A31
Implementing a nationwide criteria-based emergency medical dispatch
system: a register-based follow-up study
Mikkel S Andersen1,2*, Søren Paaske Johnsen2, Jan Nørtved Sørensen3,
Søren Bruun Jepsen4, Jesper Bjerring Hansen1, Erika Frischknecht Christensen1
1
Research Department, Prehospital Emergency Medical Services, Aarhus,
Central Denmark Region, Denmark; 2Dept. of Clinical Epidemiology, Aarhus
University Hospital, Denmark; 3Emergency Medical Communication Center,
Capital region of Denmark, Denmark; 4Emergency Medical Communication
Center, Odense University hospital, Region of Southern Denmark, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A31
Background: The organization of prehospital care in Denmark has
recently been fundamentally revised. All 112 calls concerning illness and
injury are now redirected to one of five emergency medical communication centers (EMCCs), staffed with nurses, paramedics and doctors.
Assessment of 112 callers with medical problems has up until now, been
conducted mainly by the police. The EMCC staff uses a priority dispatch
protocol (The Danish Index for Acute Care) to divide all callers into five
levels acuity (A-E), level A being patients with potential life-threatening
symptoms.
We present the first data on mortality, admission rate and level of acuity
of patients after implementation of emergency medical dispatch in
Denmark.
Methods: A follow-up study conducted in the tree largest regions in
Denmark, representing 75 % of the Danish population. During a six
months period, all 112 callers in contact with an EMCC where included in
the study. Information on vital status and hospital contacts where
obtained through national population-based registries.
Results: In total we identified 99,855 contacts to the EMCC via the 112
alarm number. 67,135 had information registered sufficiently for further
investigation. 51.4% was assessed as acuity level A, 46.3% as B, 2.1% as C,
0.2% as D (level E not included). The case fatality rate for acuity level A
patients on the same day as the 1-1-2 call was 4.4% (95% CI=4.1-4.6).
This case-fatality rate was 14.3-fold (95 % CI=11.5-17.9) higher than for
acuity level B–D patients. The hospital admission rate for acuity level A
patients was 64.4% (95% CI=63.8-64.9). There was a significant trend
(p<0.001) towards lower admission rates for patients with lower levels of
acuity.
Conclusion: The majority of patients were assessed as acuity level A or B
according to the Danish Index for Acute Care. Case fatality and hospital
admission rates were substantially higher for acuity level A patients than
for acuity level B–D patients. Using case fatality and hospital admission
rates as indicators of case severity, the newly implemented Danish
criteria-based dispatch system appears to effectively triage patients
according to the severity of their condition.
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
A32
Inter-rater agreement of the triagesystem RETTS-HEV
Louise Nissen1*, Hans Kirkegaard2, Noel Perez1, Ulf Hørlyck1, Louise Pape3
1
Emergency Department, Regionshospital Herning hospital, Denmark;
2
Research Center for Emergency Medicine, Aarhus University Hospital,
Denmark; 3Dept. of Occupational Medicine,Regional Hospital Herning,
Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A32
Background: The purpose of this study was to evaluate the inter-rater
agreement among nurses using the triage system REETS- HEV (rapid
emergency triage and treatment system-hospitalsenheden vest) in a
Danish ED.
The use of triage systems in Denmark has recently been implemented
together with structural changes in hospital organization. Testing and
evaluation is therefore needed. The REETS-HEV is a five scale triage system
being used in the Emergency department (ED) of Herning, Denmark since
May 2010. The ED is semi-large with 29,000 annual visits.
Methods: Consecutive patients presenting to the ED were assessed by
both a duty and study nurse using REETS-HEV. Nurses did not receive
training prior to the study. 146 patients were enrolled and a blinded,
paired and simultaneous triage was conducted independently to evaluate
inter-rater agreement using Fleiss kappa.
Results: A total of 155 patients were triaged over a 10 day period and
complete data were available for 146 patients. We found the overall
agreement to be good (Fleiss kappa 0.60 (0.48; 0.72)). The kappa estimate
was higher for the group of patients needing immediate attention (0.83
(0.18;1.47)).
Conclusion: The study demonstrated good inter-rater agreement
between two independent observers not receiving any new triage
training prior to the study.
A33
Leading consultants in the emergency departments are more in favour
of a specialty in emergency medicine than their collaborating
colleagues
Julie Mackenhauer1,3*, Nina Bjerre Andersen2, Hans Kirkegaard1
1
Research Center for Emergency Medicine, Aarhus University Hospital,
Denmark; 2Centre for Medical Education, Aarhus University, Denmark;
3
Akutafdelingen, Sygehus Vendsyssel, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A33
Background: In 2007 the Danish Health and Medicines Authority decided
to reorganize the acute care area, establishing common emergency
departments (ED). As emergency medicine (EM) is not an independent
specialty in Denmark, EDs are staffed by consultants from other
specialties.
The aim of this study was to examine leading consultants’ - both from
the ED and collaborating departments - knowledge of the EM discipline
description (fagområdet), and their opinion on its contribution to the
acute area, as well as potential benefits of an independent specialty.
Methods: An electronic questionnaire was sent to leading consultants
from the ED (September 2012) and collaborating departments (January
2013); ICU, surgery, orthopedics, internal medicine, cardiology, clinical
biochemistry and radiology. Answers were reported on a 5-point Likertscale(from Highly disagree-Highly agree) or yes/no.
Results: 101 of 137 collaborating leaders (74%), and 21 ED leaders (100%)
replied.
95% (n=20) of ED leaders and 50% (n=49) of collaborating leaders have
knowledge of the EM discipline description.
Of these 23% (n=16) highly agree and 30% (n=21) agree that a specialty
in EM will have a more positive impact on the cooperation between EDs
and collaborating specialties in comparison with the discipline. 17%
(n=12) disagree and 9% (n=6) highly disagree, 20% (n=14) answered
neither/nor. Comparing Likert-scale means, ED leaders had a significantly
higher level of agreement (p=0,0470, Wilcoxon 2-sample test).
Page 11 of 17
Answering if EM should be an independent specialty in Denmark,
orthopedics or leaders from Region Sjælland stood out with median
Likert-scores of 4.5 [3.75;5] (IQR) and 4 [3;5] (IQR) respectively, in contrast
to leaders from internal medicine or Region Syddanmark, who had
median Likert-scores of 2 [1.75;4.25] (IQR) and 2 [2;3.75] (IQR) respectively.
ED leaders had a significantly higher level of agreement compared
to collaborating leaders in general with 5 [3;5] (IQR) vs. 3 [2;4](IQR)
(p=0,0149, wilcoxon 2-sample test).
Conclusion: Only 50% of collaborating leaders cooperating with the EDs
know about the discipline description. Of leaders aware of the discipline
description, 53% agree or highly agree an independent specialty, more
than the discipline, will have positive impact on the cooperation between
the ED and the collaborating department. Supporting an independent
specialty varies with the leaders affiliation to specialty and region.
A34
Loss of independence: a novel but important global marker of illness
Mikkel Brabrand1*, Jesper Hallas2, Torben Knudsen1
1
Department of Medicine, Sydvestjysk Sygehus Esbjerg, Denmark; 2Research
Unit of Clinical Pharmacology, University of Southern Denmark, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A34
Background: As part of the assessment of all medical patients, vital signs
are registered. However, each vital sign on its own (e.g. blood pressure,
respiratory rate, pulse or peripheral oxygen saturation) only provide parts
of the picture and are not considered global markers of illness. Loss of
independence (LOI) (e.g. ability to stand, get into bed or out of a chair
unaided) has been proposed as a global marker of illness. The present
study present data on the association between LOI and 30-day mortality
in acutely admitted medical patients.
Methods: This was a prospective observational cohort study. Acutely
admitted adult medical patients over a six months period at the medical
admission unit at Sydvestjysk Sygehus Esbjerg were included. Upon arrival a
nurse registered vital signs and LOI (defined as the ability to get into bed
unaided). After inclusion of all patients, survival status was extracted from
the Danish Civil Register. The association between LOI and 30-day mortality
was assessed using both univariable analysis (Chi-square test) and
multivariable logistic regression analysis controlling for the vital signs. Data
will be presented as median (inter quartile range) or proportions.
Results: A total of 5,894 patients were admitted (age 65 [49-77], 50.1%
female) and 332 (5.6%) died within 30 days. LOI was reported on 5,064
patients (85.9%). Patients who had LOI had a significantly higher 30-day
mortality, 16.7 vs. 2.0%, p < 0.001, Odds Ratio (OR) 9.63 (95% confidence
interval [CI] 7.35-12.62). Patients with LOI were significantly older, had a
lower systolic blood pressure and peripheral oxygen saturation and a higher
pulse and respiratory rate and more patients had reduced level of
consciousness. LOI had a sensitivity for 30-day mortality of 70.5% (95% CI
64.7-75.8), a specificity of 80.1% (79.0-81.3), positive predictive value of
16.7% (14.6-19.0) and a negative predictive value of 98.0% (97.5-98.4). In
multivariable logistic regression analysis controlling for age, sex, systolic
blood pressure, pulse, temperature, respiratory rate and peripheral oxygen
saturation, LOI had an OR of 4.2 (95% CI 3.06-5.85), p < 0.001.
Conclusion: LOI is a powerful marker of 30-day mortality of acutely
admitted medical patients.
A35
Massive underreporting of type II Diabetes in emergency department
admissions
Josefin Gustafsson*, Søren Wistisen Rasmussen, Thomas Schmidt-Andersen
The Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A35
Background: The prevalence of type 2 diabetes mellitus (T2DM) has
continued to increase in developed and developing countries in past
decades. T2DM is the most frequent chronic disease in Denmark with a
prevalence of 4 %, with an equal estimated prevalence of undiagnosed
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
cases. T2DM is associated with several complications that can lead to acute
deterioration and need of acute admittance to the hospital. Every day
10 patients die from T2DM-related complications in Denmark. The objectives
of this study were: 1) to establish the number of patients with T2DM
referred to the Department of Internal Medicine via the Emergency
Department and the number of patients who were diagnosed with T2DM
upon referral; 2) to report which anti-diabetics they used at the time of
admittance.
Methods: A chart review during a 1 year period was conducted, i.e. from
01-JUL-2011 to 30-JUN-2012 looking at all registered cases of T2DM
including both primary and secondary diagnosis.
Results: The Emergency Department yearly admits and refers around 18,000
internal medicine patients. A total of only 31 cases with T2DM were captured.
Twenty-eight were known to have T2DM and three were diagnosed with the
disease at admittance. Oral anti-diabetics had been prescribed to 67% of
patients, oral anti-diabetics in combination with either GLP-1 agonist or
insulin to 17%, leaving 13% of the patients with insulin.
Conclusion: With a T2DM prevalence of 4%, the expected number of
admissions was 720 patients. This indicates an underreporting of T2DM of
approximately 96%, which probably results from registration of complications
related to T2DM and not the underlying disease itself. Because T2DM is
regarded as a global epidemic, registration of patients with T2DM needs to
be improved so that the quality of both primary and secondary care can be
ensured. Because of underreporting the reported anti-diabetic treatment is
unlikely to be representative.
A36
Medical students improve their self-assessed ability in managing acute
situations after simulation-based training
Louise Simonsen1*, Ian Henriksen2, Nicolai Helligsøe Bæk1, Doris Østergaard3
1
Department of Anaesthesiology, Bispebjerg Hospital, Denmark; 2Department
of Thorax Anaesthesiology, Rigshospitalet, Denmark; 3Danish Institute of
Medical Simulation. Herlev Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A36
Background: Earlier studies have pointed out that medical students feel
unprepared in their clinical clerkships in recognizing the acute, critically ill
patient and begin initial treatment. The aim of this study was to determine if
a 1- day simulation-based training course could improve medical students´
self-assessed ability to manage the acute, critically ill patient.
Methods: Medical students in their surgical or medical clinical clerkship in
the Capital Region of DK were invited to participate in one day simulatorbased training course. The students were divided into groups of 4-7
students. They were trained in managing acute medical scenarios such as
respiratory and/or circulatory failure with special focus on using the ABCDE
assessment approach. Methods used were lectures, workshops and
simulation-based training followed by feedback sessions. Before and after
training, the students rated their ability to 1) perform an ABCDE assessment,
2) recognize when a patient is critically ill, 3) begin treatment of respiratory
failure, and 4) of circulatory failure. Finally the students evaluated their
professional development during the course, their overall benefit from the
course and if they would recommend simulation training as an integrated
course in their clinical clerkships.
Results: A total of 171 students initiated the course and 160 completed the
pre- and post questionnaire. The proportion of students, who rated their
self-assessed ability to perform a ABCDE assessment and to recognize a
critically ill patient as ‘good’ to ‘very good’ improved from 27% to 71% and
from 22% to 68%, respectively.
The proportion of students who rated their ability to begin initial treatment
of a patient with respiratory or circulatory failure as ‘good’ to ‘very good’
improved from 12% to 56% and from 12% to 60%, respectively.
A total of 97% of the students would recommend simulation based
training as an integrated part of their clinical clerkship. A total of 90%
and 95%, respectively rated their professional development and their
overall course benefit as ‘good’ or ‘very good’. P-values < 0,001.
Conclusion: A significantly improvement in medical students´ selfassessed ability in recognizing an acutely, critically ill patient and in
beginning the initial treatment were seen after a 1-day simulation based
training course.
Page 12 of 17
A37
No link between social admissions of elderly people and
Christmas time
Gitte Colaco*, Thomas A Schmidt
The Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A37
Background: It is often said that Christmas and Public Holidays has an
influence on people’s physical, social and emotional well-being, and
Christmas is furthermore associated with traditions and family gatherings.
But for some people Christmas does not bring joy or good memories;
especially for the elderly with chronic diseases, bad family relations or no
family at all, Christmas can be a troublesome time. Therefore it is almost
mythically assumed that there is an increase in the number of social
admissions of elderly during Christmas compared to similar dates not
related to a Public Holiday. The scope of this study was to put this myth to
the test.
Methods: The year chosen for collection of data was the year 2011 and
Christmas was defined to be on the 23rd, 24th and 25th December. Dates
for comparison were chosen to be 11th, 12th and 13th November because
November is a month that is closely related to December regarding
seasonal diseases. The chosen weekdays are the same as in December. The
study was performed as a chart review of patients referred to the General
Department of Internal Medicine via the Emergency Department (ED):
Inclusion criteria: Elderly aged >=70 years and an admission of
maximum 24 hours (”unnecessary” admittance). The total number of
admittance i.e. all ages and the admittance of patients >=70 years with a
length of stay longer than 24 h were also captured.
Results: The reason for the admissions for both months was mostly
related to complaints regarding pain. Most of the patients had a spouse
or children, who they had contact with (Table 1).
Conclusion: For short term admissions of elderly aged 70 years or more,
the findings show, that there was no increase in social or any other
admissions to the General Department of Internal Medicine via ED during
the Christmas Holidays. A myth apparently discredited.
A38
Patients experience satisfaction and less initial waiting time after
implementation of an Emergency Department with an observation unit
Maria Søe Mattsson*, Hanne B Jørsboe
Emergency Department, Nykøbing F. hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A38
Background: Patients’ experiences are an import guide to improvements
in developing an Emergency Department (ED). Therefore, in 2009, when
the ED at Nykoebing Hospital was established, a large group of patients
were interviewed few hours after arrival. They generally expressed high
Table 1 (abstract A37)
Total All
ages
Total Age ≥ 70
years
24 hour
admission
11-NOV-2011
44
16
5
12-NOV-2011
37
14
5
13-NOV-2011
42
16
2
Total
November
123
46
12
23-DEC-2011
44
20
6
24-DEC-2011
36
11
4
25-DEC-2011
51
15
2
Total
December
131
46
12
Admission
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
degree of satisfaction with the treatment. Now, three years after, a
comparable population has been interviewed to follow up after the
comprehensive intervention of building up an ED. Special attention was
given to the overall satisfaction with the treatment, supplemented with
specific questions about initial waiting time and cooperation among staff.
Methods: Interventional study based on structured interviews with a
questionnaire containing 15 validated questions with a 5-point scale some related to LUP, supplemented with department-specific questions.
The study was initiated in 2009 and repeated again in 2012. The
interventions were a package of measures. The inclusion criteria were;
patient seeking ED; 18 years old or older; oriented and were able to give
informed consent. Patient were triaged as orange, yellow or green and
admitted to the ED for a minimum of two hours. Chi-square (chi2) for
significance testing and a confidence interval of 95% was used.
Results: Three years after establishment of the ED, 95% of the patients
(N=579, 293 M, 286 W, mean age 63) where either satisfied or very
satisfied with the treatment, which compares to the study in the very
early days of the ED (N=388, 188 M, 195 W, mean age 64). Data shows a
significant improvement in the patients’ experience of initial waiting time,
14% in 2012 compared to 42% in 2009 (p<0.05). 90% of the patients
perceived the same cooperation among staff groups before and after the
implementation.
Conclusion: A huge reorganization of the service of acutely ill patients had
no negative impact on patients overall satisfaction. Patients experienced the
same cooperation among staff groups. A benefit has been active concerning
waiting time, where the study shows a significant reduction in the perceived
initial waiting time.
A39
Point-of-care ultrasound in patients with suspected deep vein
thrombosis (DVT)
Mohammad Al hashimy1*, Kim Hvid Benn Madsen2,
Thomas Andersen Schmidt3
1
Emergency Department, Holbaek Hospital , Denmark; 2Emergency
Department, Holbaek Hospital , Denmark; 3Emergency Department, Holbaek
Hospital , Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A39
Background: Suspicion of Deep vein thrombosis (DVT) is a frequent cause
of presentation in emergency departments (EDs). Traditionally at Holbaek
University Hospital, patients presenting with suspected lower-extremity DVT
are commonly assessed and treated as out-patients in the Quick Diagnostic
Unit (QDU), a part of our Emergency Department. The patients undergo
D-dimer testing and Wells score followed by ultrasound (US) only if the
D-dimer is positive, or the patient is judged clinically to have DVT (Wells
score>2). Unfortunately, the limited availability of radiologist-performed
ultrasound outside banker’s hours delay the diagnosis by more than
24 hours and may expose the patient to inappropriate anticoagulation
treatment. The safety, ease of use, rapid time of diagnosis, low cost and
accessibility makes bedside ultrasound for DVT especially useful for
emergency physicians.
The aim of this pilot study is to assess the time-to-diagnosis and the
accuracy of emergency physician performed bedside ultrasound (EPUS) in
the detecting of pathological findings (Hematoma, Baker’s cyst and
Thrombosis), in comparison with the traditional settings involving a
radiologist-performed ultrasound.
Methods: 10 patients with clinically suspected proximal DVT attending our
QDU were included in our pilot study. All patients enrolled underwent
whole-leg US performed by an emergency-physician and a radiologist.
Results: 10 patients were enrolled in this pilot study. The EPUS findings
were normal in 7 patients (70%), abnormal in 3 patients (30%).
All normal test results were confirmed by the radiologist, and 3 patients
with abnormal findings on EPUS examination were subsequently
diagnosed as having distal DVT or superficial thrombophlebitis.
The mean time-to-diagnosis of EPUS was 2:45 h (range 00:45 to 04:12h)
compared to the mean time-to-diagnosis performed by a radiologist of
27:23 h (range 04:30 h to 71:03 h), p < 0.002.
The US performed by an emergency physician had a sensitivity of 100 %
and specificity of 100 %.
Page 13 of 17
Conclusion: Our findings suggest that EPPU may be useful in excluding
pathological findings in patients with suspected DVT, and may allow
rapid discharge and avoiding unnecessary anticoagulant treatment.
Future prospective studies are warranted to confirm these findings. This
study will continue over the next few months.
A40
Prediction of in-hospital mortality and admission to ICU using vital
signs - a study of Early Warning Score as an alternative to
traditional triage
Momo Menna Illum Vendler1, Tobias Thostrup Andersen1*, Charlotte Barfod2,
Jakob Lundager Forberg2
1
University of Copenhagen, Denmark; 2Emergency Department,
Nordsjællands Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A40
Background: Triage of patients in the Emergency Department includes
scoring of vital parameters. The objective of this study was to compare
two such triage systems for assessing vital parameters - a single-parameter
system, T-vital, as used in Danish Emergency Process Triage, and a
multiple-parameter system, T-EWS, which we based on Early Warning
Score (EWS) - and correlate the triage scores to in-hospital mortality and
admission to ICU. Studies examining EWS in triage are currently limited in
number.
Methods: Using data from the Acute Admission Database of Nordsjællands
Hospital (n = 6164 admissions), we calculated and stratified EWS into four
T-EWS colour codes (red, orange, yellow, and green), testing different
stratifications’ correlation to in-hospital mortality and admission to ICU.
Afterwards, we compared the ability of the chosen T-EWS and T-vital to
predict patients at risk (red and orange category) of in-hospital mortality or
admission to ICU. The data were analysed using area under the receiver
operating curve (AUROC), sensitivity, specificity, overtriage, undertriage, and
diagnostic rates.
Results: T-vital allocated 10.6% of patients to the orange or red
category, whereas T-EWS allocated 5.8% to these categories. There was
no significant difference in the ability of T-EWS to predict in-hospital
mortality compared to T-vital (AUROC (95% CI): T-EWS = 0.74 (0.70-0.79);
T-vital = 0.76 (0.72-0.80)). Likewise, there was no significant difference in
prediction of ICU admission (AUROC (95% CI): T-EWS = 0.76 (0.70-0.81);
T-vital = 0.73 (0.67-0.79)). The specificity (95% CI) of T-EWS compared to
T-vital was higher for both in-hospital mortality (0.95 (0.94-0.95) and
0.90 (0.90-0.91), respectively) and for admission to ICU (0.95 (0.94-0.95)
and 0.90 (0.89-0.91), respectively). There was a trend of higher
sensitivity of T-vital, and no difference in overtriage, undertriage or
diagnostic rates.
Conclusion: The two triage systems are largely similar in their ability to
discriminate patients at high risk of in-hospital mortality or admission to
ICU. However, T-vital’s larger proportion of orange and red patients might
yield a larger workload in the Emergency Department. Replacement of
T-vital with T-EWS could be considered, as EWS is already in use as a
monitoring tool after triage, but more studies are needed for further
clarification.
A41
Predictors of acute admission of more than 48 hours duration
Erlend Aabel1, Christer Aas Hansen1, Christian Backer Mogensen2*
1
Faculty of Health Sciences, University of Southern Denmark, Denmark;
2
Akutforskningsenheden, Sygehus Sønderjylland, Aabenraa, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A41
Background: When a patient is admitted to an Emergency Department
(ED) in the Region of Southern Denmark, estimation is required whether
the patient is expected to remain hospitalized for more or less than
48 hours. If the length of stay (LOS) is expected to be less than 48 hours,
the patient stays in the ED until discharge. If LOS is expected to exceed
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
48 hours, the patient is transferred to the relevant department. The aim
of this study was to investigate if information available at admission
could be used as predictors of LOS, and to determine which group of
staff (nurses, junior physicians or senior physicians) was best able to
estimate the correct LOS.
Methods: A prospective cohort study with collection of data on admitted
patients in the ED Aabenraa over a period of 35 days. Information on
admission was collected including age, comorbidities (Charlson score),
sociodemographic factors, alcohol consumption and smoking habits. The
ED staff was asked to give their prediction of LOS. The main outcome
was LOS. Data was collected on a total of 730 patients. Analysis was
performed using Chi-square test, Kruskal-Wallis test and multivariable
logistic regression.
Results: Significant predictors of LOS exceeding 48 hours were age >80
years (OR 2.69; CI 1.28-5.67), Charlson score 1-2 (OR 2.04; 95% CI 1.053.97) and Charlson score >=3 (OR 5.55; 95% CI 2.24-13.78). Senior
physicians had the highest accuracy (77%) for LOS and an OR of 8.18
(95% CI 1.92-34.78). Sensitivity was low for all staff, with senior physicians
having the highest (56.7%). There was no statistically significant
difference in correct estimation of LOS between nurses and junior
physicians.
Conclusion: A general underestimation of LOS was observed among all
staff. The estimation of expected length of stay should be assigned to
senior physicians. Age and Charlson score can be included in a clinical
prediction model to aid the estimation.
A42
Prehospital fentanyl administration by ambulance personnel
KF Christensen1,2,3*, L Nikolajsen1, H Kirkegaard2, EF Christensen3
1
Dept. of Anesthesiology, Aarhus University Hospital; 2Research Center for
Emergency Medicine, University of Aarhus; 3Research Dept., Prehospital
Emergency Medical Services, Central Denmark Region Aarhus, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A42
Background: Acute pain is one of the most common problems faced in
prehospital emergency medicine. Sufficient prehospital pain therapy
reduces psychological and emotional stress. Other clinical benefits include
optimized conditions for patient transport, increased patient satisfaction
and a better chance of timely and proper analgesia at the emergency
department. Unfortunately, undertreatment of acute pain (oligoanalgesia)
is common. Oligoanalgesia is associated with following factors:
• Variable clinical experience
• Concern for masking illness or injury
• Focus on other clinical symptoms
• Poor education in pain management and insufficient compliance with
pain management protocols
• Fear of inducing adverse effects
• Lack of follow-up after initial pain therapy administration
Methods: One approach to minimize oligoanalgesia is to increase the use
of fentanyl in the prehospital environment. Fentanyl is an opioid with
rapid-acting properties and short time of action allowing safe titration
and few side effects.
In order to optimize prehospital pain management all ambulance
personnel in Central Denmark Region have been taught how to
administer fentanyl in specific clinical situations and under certain
circumstances. We wish to present the preliminary results from a 3-month
period in which rescuers working for one of the two ambulance
companies operating in the region, Responce and Falck, were allowed to
administer fentanyl.
Results: A total of 204 patients were treated with fentanyl by ambulance
personnel over a period of 3 month. About one half had some kind of
injury (n=114) and the remainder experienced pain due to acute coronary
syndrome (n=52), abdominal pain (n=18) or other clinical conditions
(n=20). None of the patients experienced side effects. Antidote was not
required in any of the cases.
Conclusion: The administration of fentanyl by ambulance personnel
seems to be safe. Future studies will further evaluate pain and the safety
Page 14 of 17
and effectiveness of fentanyl administered by ambulance personnel in
Central Denmark Region.
A43
Prevention of pressure ulcers at orthopaedic patients begins on the
accident and emergency department
Mai Sommer1*, Gitte Boier Tygesen2, Anne Jacobsen2
1
Orthopaedic ward, Hospitalsenheden Horsens, Denmark; 2Accident and
Emergency Department, Hospitalsenheden Horsens, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A43
Background: Hospitalization causes many pressure ulcers and has
important implications for the patient and the economy. Regional hospital
Horsens is one of 5 hospitals in Denmark participating in ‘The Danish Safer
Hospital Programme’ where one aim is to reduce and prevent pressure
ulcers. The target for the hospital is to reduce pressure ulcers to less than
5% and the aim is to, asses the risk of getting pressure ulcers (screen) to
90% of the patients.
The Accident and Emergency Department (A&E) undertake the first
evaluation of patients’ risk of developing pressure ulcers and this
evaluation is basis for the screenings in the forward progress of the
patient.
Baseline measurements showed, 4 out of 10 patients experienced pressure
ulcers. The cause was identified in lack of systematic observations,
documentation and individual staff members’ competence levels. A need
was identified for all staff to possess the same level of knowledge about
prevention and tools to support this.
Methods: The intervention started August-2010 in the Orthopaedic ward
and in January-2012 the A&E joined and consisted:
Staff members’ competencies (training and bed-side education);
Tools for systematic observation (Braden Guidelines );
Involvement of patients by providing information;
Easy access to equipment (low air fluidized beds/pillows)
All pressure ulcers of grade 1 and above were registered by nurses and
validated by journal reviews and compared to the numbers of discharged
patients.
Results: Before the intervention, the percentage of the screenings showed a
40-50% occurrence of pressure ulcers at patients admitted through A&E to
the Orthopaedic Ward. The study shows a decrease in amount of pressure
ulcers to less than 0.5% at the Orthopaedic Ward, in addition 90% of the
patients had assessed their risk.
Conclusion: By assessing the risk of getting pressure ulcers and continue
the systematic observation, it seems like the target is reached. It’s not
possible to conclude that the decrease, is due solely to the intervention, this
needs statistical analysis and controlled studies.
Start of screening in A&E, targeting and follow-up actions in the Orthopaedic
ward do seem to reduce pressure ulcers and the message is to think
progress starting in A&E.
A44
Reporting vital parameters upon referral of patients to the emergency
department needs to be improved
Christina Bach*, Thomas A Schmidt
The Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A44
Background: The purpose of triage is to prioritize patients and identify
those who need immediate attention. Primary triage is attempted by the
coordinating physician at the Emergency Department (ED) based primarily
on the patient’s vital parameters (blood pressure, heart rate, oxygen
saturation, respiration rate and body temperature) received by phone from
the referring party, i.e. paramedics or general practitioners (GPs). Secondary
triage of the patients is performed minutes after arrival to the ED by nurse
or physician. Based on symptoms or by observations of vital parameters,
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
patients are allocated to four different triage categories according to
severity. Patients referred by paramedics are subject to basic observations of
vital parameters that allow primary triage and subsequent ED preparedness.
In this study we evaluated whether the information obtained in the
conversation with GPs was sufficient to perform meaningful primary triage.
Further, we wanted to elucidate the correlation between primary and
secondary triage.
Methods: The study was a double-blinded prospective observational
study. The triage-information cards from patients referred from GPs
during daytime were obtained over five days randomly selected over five
weeks (all weekdays were represented).
Results: A total of 50 patients were included. Out of these primary triage
was attempted / deemed meaningful in merely 38% (19/50) of the cases. In
only 18% (9/50) of the cases any vital parameters were reported from the
GP, and for none of the patients admitted all vital parameters were
reported. Of the admitted patients with vital parameters reported, only in
44% (4/9) of the cases primary triage was attempted. Of all patients
admitted merely 32% (16/50) received both primary and secondary triage.
Of these 81% (12/16) were subjected to the same severity category in both
triage rounds.
Conclusion: The information received from GPs referring patients to the ED
is limited with regard to vital parameters, and not sufficient to conduct
primary triage. The results indicate that when primary triage is performed, it
correlates well with secondary triage. Collaboration between referring
physicians and the ED should be improved with regard to reporting the
patient’s vital parameters.
A45
Spontaneous nosebleeds in the emergency department setting characteristics, co-morbidities and treatment efficacy
Irfan Rafique*, Thomas A Schmidt
The Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A45
Background: Spontaneous nosebleed (SN) is a common cause of visits in
Danish emergency departments (ED). The aim of this study was to examine
these visits during 1 whole year. We examined the number of visits,
characteristics of the patients in terms of sex, age, co-morbidities, and
treatment of the SN.
Methods: Data was extracted from patient records from Holbaek University
Hospital. Patients diagnosed with nosebleeds according to the ICD10
classification were sought for in the period 1th October 2011 up to and
including 30th September 2012. Nosebleeds due to any kind of trauma were
excluded.
Results: The total number of SNs was 152. Of these 31 were re-visits hence
121 individuals, 54 (45%) female and 67 (55%) male. The age ranged from 2
up to and including 94 years, and age composition was similar in both
genders. No patients were found in the age range of 23 up to and including
36. There were 16 (13%) patients below and 105 (87%) above this age
range, categorized as younger patients (YP) and older patients (OP),
respectively.
YP had no comorbidities and 7 needed conservative treatment using a
nasal clamp or putting an ice cube in the mouth.
70 (67%) of the OP had one or more of the following conditions / comorbidities, using anticoagulant drug treatment (43 patients), hypertension
(33 patients), nasal or haematological anomaly (9 patients).
35 (33%) of all OP needed no treatment, 23 (22%) were treated only
conservatively and 47 (45%) with RapidRhino®. RapidRhino® was used for 10
(29%) of healthy OP and for 37 (53%) with co-morbidities.
Conclusion: SN is a condition that frequently appears in EDs. However, no
patients were found in the age range 23 up to and including 36, which
implies that young adults are not prone to SN. YP needed only conservative
treatment, whereas almost half of the OP were treated with a RapidRhino®. If
the SN had not ceased spontaneously few OP benefitted from conservative
treatment only, especially if they had co-morbidities. This study suggests that
conservative treatments in adults are of some benefit, but other means of
treatment are mostly necessary.
Page 15 of 17
A46
The quality of EDIFACT referrals from primary care to the emergency
department
Hanne Hestbech*, Søren W Hansen, Thomas A Schmidt
The Emergency Department, Holbaek, University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A46
Background: Communication between primary care and the Emergency
Department is in most cases provided through written referrals. The
quality is very important to create coherent clinical courses, treatment of
high quality and high satisfaction among patients. 95% of all admissions
from primary care are delivered as EDIFACT, which is a secure way to
send electronic post and to ensure immediate delivery. There’s already a
guideline that describes the requirements to EDIFACT admissions but no
studies describe the quality and the use of them.
Methods: A retrospective study that included 228 patients admitted to
the Emergency Department from primary care. We registered all admitted
patients on 10 randomly selected weekdays in the period from the 1st of
October to the 15th of December 2012. Only patients admitted from
primary care via EDIFACT were included. All admissions have been
thoroughly read and the content compared with the guideline.
Results: 419 patients were admitted to the Emergency Department on 10
randomly selected days. Of these 419 patients 228 were admitted from
primary care but only 140 (61%) were referred by EDIFACT. All referrals
(100%) contained medical history, 16 admissions (11%) contained
information about allergies, 44 admissions (31%) contained information
about the patient’s medication and 32 admissions (23%) contained
information about vital parametres.
Conclusion: It may be concluded that the quality of EDIFACT referrals
from primary care varies a lot, but we also registered that the guideline
isn’t available for doctors in primary care. This isn’t appropriate because
important information about admitted patients is lost which results in
poorer clinical courses. The 1st of January 2013 new and better
guidelines are published which is a good possibility to clarify the
importance of EDIFACT referrals. Because of time pressure in primary care
one might consider the possibility of developing a new program in which
information about the patient’s medication and allergies are captured
directly from the primary care charts. This might ensure that important
information isn’t lost when doctors in primary care are communicating
with the Emergency Department.
A47
Timing of antibiotic treatment among infected patients with- and
without fever - a prospective cohort study in a medical
emergency department
Daniel Pilsgaard Henriksen1*, Christian Borbjerg Laursen2,
Annmarie Touborg Lassen1
1
Medical Emergency Department, Odense University Hospital, Denmark;
2
Department of Respiratory Diseases, Odense University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A47
Background: Infection is one of the most frequent causes of medical
admissions to the emergency department in the adult population.
However not all infected patients present with fever (>38º Celsius). As
early administration of antibiotic is related to improved prognosis, the
aim of the study was to compare the “door-to-antibiotics” time in
infected patients admitted to the medical emergency ward with- and
without fever at arrival.
Methods: Prospective observational cohort study of all patients admitted
acutely to the medical emergency ward, Odense University Hospital
(September 1st 2010 – August 31st 2011). At arrival all patients had their
temperature measured (rectal). After discharge, all patient records were
evaluated manually and patients with infection were identified due to the
National Healthcare Safety Network criteria of infections in combination
with clinical judgment where focus was clinically evident. Time of
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
antibiotic treatment was extracted electronically from the electronic
patient journal.
We included all adult (≥15 years of age) patients with a first time admission of
community-acquired infection within the inclusion period with a registration
of antibiotics within the first 24 hours after admission (ATC: J01*).
Results: There were 8133 admissions in 6257 different patients. 1987
patients fulfilled the inclusion criteria. 1003/2003 (50.5%) presented with
fever and 984 (49.5%) without fever. Median age for patients with fever was
69.9 years (range 15.1-99.3 years) and without fever 76.0 years (range 15.0101.8 years, p<0.0001). Patients with fever more often were male (50.4% vs.
43.9%, p=0.004), but less often had severe comorbidity (Charlson index >2
38.7% vs. 46.3%, p=0.001) than among patients without fever.
In patients with fever, the median time to antibiotic administration was
4.1 hours (IQR 2.5 - 6.3 hours) compared with patients without fever 5.9
hours (IQR: 3.7 – 9.3 hours) p<0.0001. For patients with pulmonary focus
the time to antibiotics were 4.0 vs. 5.8 hours, p<0.0001 in patients with
and without fever, urinary focus 4.0 vs. 6.7 hours, p<0.0001 and
abdominal focus 5.2 vs. 7.8, p=0.004.
Conclusion: Infected patients with fever have antibiotics administered
earlier than infected patients without fever. Infected patients with fever
are younger and have less severe comorbidity than infected patients who
present without fever.
A48
Treatment of transfusion requiring anemia in a Quick Diagnostic Unit
integrated in an Emergency Department Setting
Charlotte Stenqvist*, Søren Wistisen Rasmussen, Thomas Andersen Schmidt
The Emergency Department, Holbaek University Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A48
Background: The establishment of a Quick Diagnostic Unit (QDU) in an
Emergency Department (ED) setting has allowed expeditious blood
transfusion of anaemic patients. The purpose of the study was to
establish the mode of referral, describe the clientele, determine the
underlying diseases and the Hb level of the referred patients.
Methods: Chart review of an 8 month period. Values were given as mean
± SEM. Significance was evaluated using Student’s two-tailed t-test for
unpaired observations. The level of significance was p < 0.05.
Results: We found 108 patients. 71% was referred to hospital by their
general practitioner and 18% of the patients came from oncological
departments. In the given period we treated around 4 patients each
week. 25 patients were admitted more than once, on average they came
every 42nd day. Two thirds of the patients only stayed for a few hours.
55 patients had a diagnosed cancer, 29 were men and 26 were women.
53 patients had a nonmalignant disease, 26 were men and 27 were
women. The mean age for oncological patients was 73.8 ± 1.3 (n = 55)
years and for nonmalignant patients 75 ± 1.8 years (n = 53) (p > 0.6).
Oncological patients were given SAG-M transfusions at a Hb level of 5.0 ±
0.09 mMol/L (80.4 ± 1.4 g/L). Nonmalignant patients received SAG-M at a
Hb level of 4.7 ± 0.07 mMol/L (75.7 ± 1.1 g/L) (p < 0.05).
On average patients with malignant disease tended to receive less blod
than patients with nonmalignant diseases (p=0.06), i.e. 2.2 ± 0.1 vs. 2.5 ±
0.1 SAG-M per contact. This however in clinical practice amounts to 2
SAG-M for both patient categories.
Conclusion: SAG-M transfusion may be given expeditiously in a QDU setting
to elderly patients. On average oncological patients received SAG-M at a
higher Hb level than other anemic patients. The transfusion tigger for patients
with nonmalignant disease appears to comply with national guidelines.
A49
Triage of children in an Emergency Department
Dennis Graversen1*, Ann-Britt Kiholm Kirkedal2
1
Emergency Department, Holbaek Hospital, Denmark; 2Department of
Paediatrics, Holbaek Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A49
Page 16 of 17
Background: To secure the best primary treatment of children a
nationwide triage system has been instituted. The aim of this study
was to evaluate the primary implementation in an Emergency
Department(ED).
Methods: Through a retrospective evaluation of medical records vital
parameters and triage assessments made by an ED nurse were collected.
Children younger than 13 years of age with no referral from a doctor
were included (from October to December 2012) (n=127).
Results: A total of 81.9% (n=104) of the children were registered with
triage colour indicating the level of urgency. This was done within a
mean of 26.4 minutes from time of arrival. Children younger than 1 year
old were significantly more likely not to be triaged compared to children
older than 1 year old RR 2.78 (95% CI 1.31-5.93) (p=0.0249). Distribution
of triage was; green (lowest level) 58.3%, yellow 24.4%, orange 16.5% and
red (highest level) 0.9%. In 22.1% of the patients we identified a lower
triage level than given with the vital parameters . The greatest risk of
being under-triaged was found among children between 3-7 years
(39.4%).
Conclusion: A simple and clear triage system is of great importance in
order to get a well functioning triage in an ED. We showed that special
attention should be given to infants to secure proper triage and that
children from 3-7 years of age is at the highest risk of being undertriaged.
A50
Triage of patients for emergency medical team based on pre-hospital
observations
Christian Melchior Olesen1*, Christian Baaner Skjærbæk2, Leif Rognås1
1
Department of Anesthesiology, Viborg Hospital, Denmark; 2Department of
Medicine, Viborg Hospital, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A50
Background: Critically ill patients are likely to benefit from being
received by a predefined multidisciplinary team providing a structured
and well qualified initial examination and immediate treatment of lifethreatening conditions.
At Viborg Hospital all critically ill non-trauma adult patients have been
received by an emergency medical team (EMT) since January 1st 2012.
The EMT is a preformed multidisciplinary team led by senior registrars or
consultants from the Department of internal medicine and the
Department of Anesthesiology and Intensive Care. To identify those
patients that should be received by EMT and ensure optimal resource
utilization a triage system is necessary. Based on the triage system
ADAPT, we have developed a system where data from the Emergency
Medical Services form the basis for the triage.
To our knowledge, no other Danish study have evaluated the use of prehospital data for the triage of unselected critically ill non-trauma patients.
We aimed at evaluating the present triage model.
Methods: In all EMT activations we recorded the patients’ vital status, the
preliminary diagnosis and the patients’ transfer destinations when leaving
the emergency department. The physicians assessed the relevance of
team activation.
Results: 269 AMT-activations were recorded. The activation was classified
as relevant in 248 cases (92%). 141 patients (52%) were transferred to the
intensive care unit. 94 patients (35%) were transferred to the emergency
medical ward or the cardiology department. 8 patients (3%) were
transferred to the surgical room and 7 patients (3%) were transferred
directly to another hospital.
Conclusion: We found that the triage-model effectively identified
patients for whom EMT-activation would not be relevant. This conclusion
is supported by the fact that a large proportion of the patients treated by
the EMT needed intensive care.
The study weakness is that we have no assessment of undertriage.
In an attempt to estimate this possible undertriage, we are currently
conducting a study of non-trauma patients who died or were transferred
to the intensive care unit within the first 24 hours after admission to
identify whether they were treated by the EMT or not.
Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2013, Volume 21 Suppl 2
http://www.sjtrem.com/supplements/21/S2
A51
Use of OTC-drugs prior to Hospitalization
Magnus Pedersen*, Mikkel Brabrand
Sydvestjysk Sygehus, Esbjerg, Denmark
E-mail: [email protected]
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013,
21(Suppl 2):A51
Background: Use of over the counter (OTC)-drugs is increasing and as it
is poorly registered, this can lead to complications. The most commonly
used OTC-drugs are analgesics and use is highest among elderly. Our
study investigates the use of OTC-drugs 24 hours prior to hospitalization
as well as the effect of the drugs.
Methods: The junior physicians on call interviewed all patients admitted
to the medical admission unit at Sydvestjysk Sygehus in Esbjerg on the
use of OTC-drugs, using a modified chart template designed for the
purpose. All adult patients aged 15 and older admitted over a two week
period in August 2012 were included. The patients were asked about the
drugs taken, dosage, indication and effect. OTC-drugs where categorised
based on ATC-codes.
Page 17 of 17
Results: From a total of 349 admissions 188 usable chart templates were
registered (54%) and information on OTC usage was registered on 165 of
these (88%). The patients were elderly (median: 70 years) and 43
reported an intake of OTC-drugs (26%). A total of 22 different OTC-drugs
had been consumed with analgesics being the most widely used (74%).
The majority of patients had taken the drugs on a relevant indication
(88%), the most common indication being pain. Half the patients had
taken the drugs in a relevant dosage (51%). Sixty percent felt an effect of
the intake and the majority on pain symptoms.
Conclusion: Our findings reveal that one in four patients use OTC-drugs
24 hours prior to hospitalization. Most patients use OTC-drugs relevantly
and half with a positive effect. The intake is poorly registered, and there
is a need for more focus on the intake of OTC-drugs to avoid potential
side-effects and medicine-interactions due to this increasing intake.
Cite abstracts in this supplement using the relevant abstract number,
e.g.: Pedersen and Brabrand: Use of OTC-drugs prior to Hospitalization.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
2013, 21(Suppl 2):A51