To determine the validity of the Manchester Triage System (MTS) in emergency care for the general population of patients attending the emergency department, for children and elderly, and for commonly ...used MTS flowcharts and discriminators across three different emergency care settings.
This was a prospective observational study in three European emergency departments. All consecutive patients attending the emergency department during a 1-year study period (2010-2012) were included. Validity of the MTS was assessed by comparing MTS urgency as determined by triage nurses with patient urgency according to a predefined 3-category reference standard as proxy for true patient urgency.
288,663 patients were included in the analysis. Sensitivity of the MTS in the three hospitals ranged from 0.47 (95%CI 0.44-0.49) to 0.87 (95%CI 0.85-0.90), and specificity from 0.84 (95%CI 0.84-0.84) to 0.94 (95%CI 0.94-0.94) for the triage of adult patients. In children, sensitivity ranged from 0.65 (95%CI 0.61-0.70) to 0.83 (95%CI 0.79-0.87), and specificity from 0.83 (95%CI 0.82-0.83) to 0.89 (95%CI 0.88-0.90). The diagnostic odds ratio ranged from 13.5 (95%CI 12.1-15.0) to 35.3 (95%CI 28.4-43.9) in adults and from 9.8 (95%CI 6.7-14.5) to 23.8 (95%CI 17.7-32.0) in children, and was lowest in the youngest patients in 2 out of 3 settings and in the oldest patients in all settings. Performance varied considerably between the different emergency departments.
Validity of the MTS in emergency care is moderate to good, with lowest performance in the young and elderly patients. Future studies on the validity of triage systems should be restricted to large, multicenter studies to define modifications and improve generalizability of the findings.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Intoxications with alcohol and drugs are common in the Emergency Department. This study aimed to describe the occurrence and characteristics of intoxications (alcohol, Drugs of Abuse (DOA), ...pharmaceutical and chemical) presented to the Emergency Department and the health care costs of these intoxications.
This was a retrospective medical record study of all patients (≥ 16 years) who presented to the Emergency Department of an inner-city academic hospital in the Netherlands due to single or multiple intoxication(s) as the primary or secondary reason in the year 2016. An intoxication was reported as present if the attending physician described the intoxication in the patient's medical record.
A total of 783 patients were included, accounting for 3.2% of the adult Emergency Department population (age ≥ 16 year). In 30% more than one substance was used. Intoxications with alcohol, Drugs of Abuse and pharmaceuticals was reported in respectively 62%, 29% and 21% of the intoxicated patients. The mean costs per patient presenting with an intoxication to the Emergency Department was € 1,490. The mean costs per patient were highest for pharmaceutical intoxications (€ 2,980), followed by Drugs of Abuse (€ 1,140) and alcohol (€ 1,070).
Intoxications among patients aged 16 years and older are frequently seen at the Emergency Department and are frequently caused by multiple substances. Alcohol is the most common intoxication. Substantial healthcare costs are involved. Therefore, this study suggests that further research into hazardous alcohol consumption and DOA abuse is warranted.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Introduction Acute pain in trauma patients in emergency care is still undertreated. Early pain treatment is assumed to effectively reduce pain in patients and improve long-term outcomes. In ...order to improve pain management in the chain of emergency care, a national evidence-based guideline was developed. The aim of this study was to assess whether current practice is in compliance with the guideline ‘Pain management for trauma patients in the chain of emergency care’ from the Netherlands Association for Emergency Nurses (in Dutch NVSHV), and to evaluate early and initial pain management for adult trauma patients in emergency care. Methods Chart reviews were conducted in three regions of the Netherlands using electronic patient files of trauma patients from the chain of emergency care. We included one after-hours General Practitioner Co-operation (GPC), one ambulance Emergency Medical Services (EMS), two Helicopter Emergency Medical Services (HEMS), and three Emergency Departments (EDs). Organisation of pain management, pain assessment, and pain treatment was examined and compared with national guideline recommendations, including quality indicators. Results We assessed a random sample of 1066 electronic patient files. The use of standardised tools to assess pain was registered in zero to 52% of the electronic patient files per organisation. Registration of (non-)pharmacological pain treatment was found in less than half of the files. According to the files, pharmacological pain treatment deviated from the guideline in 73–99% of the files. Time of administration of medication was missing in 73–100%. Reassessment of pain following pain medication was recorded in half of the files by the HEMS, but not in files of the other organisations. Conclusions The (registration of) current pain management in trauma patients in the chain of emergency care varies widely between healthcare organisation, and deviates from national guideline recommendations. Although guideline compliance differs across groups of healthcare professionals, maximum compliance rate with indicators registered is 52%. In order to improve pain management and evaluate its effectiveness, we recommend to improve pain registration in patient files. Furthermore, we advise to identify barriers and facilitators related to the implementation of the national guideline in all emergency care organisations.
There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study ...aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need.
An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days.
One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR 95%CI, 45.5 10.0-207.6, 23.4 11.1-49.3 and 32.6 9.4-113.6, respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities.
In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment.
Overuse of broad-spectrum antibiotics in emergency departments (EDs) results in antibiotic resistance. We determined whether procalcitonin (PCT) -guided therapy can be used to reduce antibiotic ...regimens in EDs by investigating efficacy, safety and accuracy.
This was a non-inferiority multicentre randomized clinical trial, performed in two Dutch hospitals. Adult patients with fever ≥38.2°C (100.8°F) in triage were randomized between standard diagnostic workup (control group) and PCT-guided therapy, defined as standard workup with the addition of one single PCT measurement. The treatment algorithm encouraged withholding antibiotic regimens with PCT <0.5 μg/L, and starting antibiotic regimens at PCT ≥0.5 μg/L. Exclusion criteria were immunocompromised conditions, pregnancy, moribund patients, patients <72 h after surgery or requiring primary surgical intervention. Primary outcomes were efficacy, defined as number of prescribed antibiotic regimens; safety, defined as combined safety end point consisting of 30 days mortality, intensive-care unit admission, ED return visit within 2 weeks; accuracy, defined as sensitivity, specificity and area-under-the-curve (AUC) of PCT for bacterial infections. Non-inferiority margin for safety outcome was 7.5%.
Between August 2014 and January 2017, 551 individuals were included. In the PCT-guided group (n = 275) 200 (73%) patients were prescribed antibiotic regimens, in the control group (n = 276) 212 (77%) patients were prescribed antibiotics (p 0.28). There was no significant difference in combined safety end point between the PCT-guided group, 29 (11%), and control group, 46 (16%) (p 0.16), with a non-inferiority margin of 0.46% (n = 526). AUC for confirmed bacterial infections for PCT was 0.681 (95% CI 0.633–0.730), and for CRP was 0.619 (95% CI 0.569–0.669).
PCT-guided therapy was non-inferior in terms of safety, but did not reduce prescription of antibiotic regimens in an ED population with fever. In this heterogeneous population, the accuracy of PCT in diagnosing bacterial infections was poor.
http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4949.
The COVID-19 outbreak disrupted regular health care, including the Emergency Department (ED), and resulted in insufficient ICU capacity. Lockdown measures were taken to prevent disease spread and ...hospital overcrowding. Little is known about the relationship of stringency of lockdown measures on ED utilization.
This study aimed to compare the frequency and characteristics of ED visits during the COVID-19 outbreak in 2020 to 2019, and their relation to stringency of lockdown measures.
A retrospective multicentre study among five Dutch hospitals was performed. The primary outcome was the absolute number of ED visits (year 2018 and 2019 compared to 2020). Secondary outcomes were age, sex, triage category, way of transportation, referral, disposition, and treating medical specialty. The relation between stringency of lockdown measures, measured with the Oxford Stringency Index (OSI) and number and characteristics of ED visits was analysed.
The total number of ED visits in the five hospitals in 2019 was 165,894, whereas the total number of visits in 2020 was 135,762, which was a decrease of 18.2% (range per hospital: 10.5%-30.7%). The reduction in ED visits was greater during periods of high stringency lockdown measures, as indicated by OSI.
The number of ED visits in the Netherlands has significantly dropped during the first year of the COVID-19 pandemic, with a clear association between decreasing ED visits and increasing lockdown measures. The OSI could be used as an indicator in the management of ED visits during a future pandemic.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
DNAJC6 mutations were recently described in two families with autosomal recessive juvenile parkinsonism (onset age < 11), prominent atypical signs, poor or absent response to levodopa, and ...rapid progression (wheelchair‐bound within ∼10 years from onset). Here, for the first time, we report DNAJC6 mutations in early‐onset Parkinson's disease (PD).
Methods
The DNAJC6 open reading frame was analyzed in 274 patients with early‐onset sporadic or familial PD. Selected variants were followed up by cosegregation, homozygosity mapping, linkage analysis, whole‐exome sequencing, and protein studies.
Results
We identified two families with different novel homozygous DNAJC6 mutations segregating with PD. In each family, the DNAJC6 mutation was flanked by long runs of homozygosity within highest linkage peaks. Exome sequencing did not detect additional pathogenic variants within the linkage regions. In both families, patients showed severely decreased steady‐state levels of the auxilin protein in fibroblasts. We also identified a sporadic patient carrying two rare noncoding DNAJC6 variants possibly effecting RNA splicing. All these cases fulfilled the criteria for a clinical diagnosis of early‐onset PD, had symptoms onset in the third‐to‐fifth decade, and slow disease progression. Response to dopaminergic therapies was prominent, but, in some patients, limited by psychiatric side effects. The phenotype overlaps that of other monogenic forms of early‐onset PD.
Interpretation
Our findings delineate a novel form of hereditary early‐onset PD. Screening of DNAJC6 is warranted in all patients with early‐onset PD compatible with autosomal recessive inheritance. Our data provide further evidence for the involvement of synaptic vesicles endocytosis and trafficking in PD pathogenesis. Ann Neurol 2016;79:244–256
We conduct a systematic review with meta-analysis to provide an overview of the different manners of providing discharge instructions in the emergency department (ED) and to assess their effects on ...comprehension and recall of the 4 domains of discharge instructions: diagnosis, treatment, follow-up, and return instructions.
We performed a systematic search in the PubMed, EMBASE, Web of Science Google Scholar, and Cochrane databases for studies published before March 15, 2018. A quality assessment of included articles was performed. Pooled proportions of correct recall by manner of providing discharge instructions were calculated.
A total of 1,842 articles were screened, and after selection, 51 articles were included. Of the 51 included studies, 12 used verbal discharge instructions only, 30 used written discharge instructions, and 7 used video. Correct recall of verbal, written, and video discharge instructions ranged from 8% to 94%, 23% to 92%, and 54% to 89%, respectively. Meta-analysis was performed on data of 1,460 patients who received verbal information only, 3,395 patients who received written information, and 459 patients who received video information. Pooled data showed differences in correct recall, with, on average, 47% for patients who received verbal information (95% confidence interval 32.2% to 61.7%), 58% for patients who received written information (95% confidence interval 44.2% to 71.2%), and 67% for patients who received video information (95% confidence interval 57.9% to 75.7%).
Communicating discharge instructions verbally to patients in the ED may not be sufficient. Although overall correct recall was not significantly higher, adding video or written information to discharge instructions showed promising results for ED patients.
The aim was to effectively reduce the unnecessary use of broad spectrum antibiotics in the emergency department (ED), patients with bacterial infections need to be identified accurately. We ...investigated the diagnostic value of a combination of biomarkers for bacterial infections, C-reactive protein (CRP), and procalcitonin (PCT), together with biomarkers for viral infections, tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), and interferon-gamma-induced protein-10 (IP-10), in identifying suspected and confirmed bacterial infections in a general ED population with fever.
This is a sub-study in the HiTEMP cohort. Patients with fever were included during ED triage, and blood samples were obtained. Using both diagnostics and expert panel analysis, all patients were classified as having either suspected or confirmed bacterial infections, or non-bacterial disease. Using multivariable logistic regression analysis, three biomarker models were analysed: model 1, CRP, TRAIL, IP-10; model 2, PCT, TRAIL, IP-10; and model 3, CRP, PCT, TRAIL, IP-10.
A total of 315 patients were included, of whom 228 patients had a suspected or confirmed bacterial infection. The areas under the curve for the combined models were the following: model 1, 0.730 (95% CI 0.665–0.795); model 2, 0.748 (95% CI 0.685–0.811); and model 3, 0.767(95% CI 0.704–0.829).
These findings show that a combination of CRP, PCT, TRAIL and IP-10 can identify bacterial infections with higher accuracy than single biomarkers and combinations of a single bacterial biomarkers combined with TRAIL and IP-10.
We modeled the geometrical roughening of bedding-parallel, mainly layer-dominated stylolites in order to understand their structural evolution, to present an advanced classification of stylolite ...shapes and to relate this classification to chemical compaction and permeability variations at stylolites. Stylolites are rough dissolution seams that develop in sedimentary basins during chemical compaction. In the Zechstein 2 carbonate units, an important lean gas reservoir in the southern Permian Zechstein basin in Germany, stylolites influence local fluid flow, mineral replacement reactions and hence the permeability of the reservoir. Our simulations demonstrate that layer-dominated stylolites can grow in three distinct stages: an initial slow nucleation phase, a fast layer-pinning phase and a final freezing phase if the layer is completely dissolved during growth. Dissolution of the pinning layer and thus destruction of the stylolite's compaction tracking capabilities is a function of the background noise in the rock and the dissolution rate of the layer itself. Low background noise needs a slower dissolving layer for pinning to be successful but produces flatter teeth than higher background noise. We present an advanced classification based on our simulations and separate stylolites into four classes: (1) rectangular layer type, (2) seismogram pinning type, (3) suture/sharp peak type and (4) simple wave-like type. Rectangular layer type stylolites are the most appropriate for chemical compaction estimates because they grow linearly and record most of the actual compaction (up to 40mm in the Zechstein example). Seismogram pinning type stylolites also provide good tracking capabilities, with the largest teeth tracking most of the compaction. Suture/sharp peak type stylolites grow in a non-linear fashion and thus do not record most of the actual compaction. However, when a non-linear growth law is used, the compaction estimates are similar to those making use of the rectangular layer type stylolites. Simple wave-like stylolites are not useful for compaction estimates, since their growth is highly non-linear with a very low growth exponent. In the case where sealing material is collected at the tooth during dissolution, stylolites can act as barriers for local fluid flow as they intensify sealing capabilities of pinning layers. However, the development of teeth and spikes offsets and thus destroys continuous stylolite seams so that the permeability across the stylolite becomes very heterogeneous and they are no continuous barriers. This behavior is best shown in rectangular layer and seismogram pinning type stylolites that develop efficient fluid barriers at teeth tips but destroy sealing capabilities of layers by offsetting them at the flank, leading to a permeability anisotropy along 2-D stylolite planes. Suture/sharp peak stylolites can create fluid barriers if they collect enough sealing material. However, if the collecting material does not seal or if spikes offset the sealing material the stylolite leaks. We propose that our classification can be used to realistically estimate chemical compaction in reservoirs and gives an indication on how heterogeneous the permeability of stylolites can be.
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•Stylolites can significantly influence fluid flow and replacement reactions.•Roughness growth dynamics are used to establish a new stylolite classification.•The new classification allows realistic compaction/permeability estimates.•Rectangular layer-type stylolites are best for chemical compaction estimates.•Previous stylolite dissolution estimates often underestimate the compaction.
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