Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians. METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire. RESULTS: The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insuf cient numbers of trained staff to support PSA in the ED and insuf cient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients. CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both quali ed in PSA and available in the ED.

Violence toward emergency physicians: A prospective-descriptive study

BACKGROUND: The highest rate of workplace violence occurs in the health sector, although most cases remain unreported. Emergency services face the majority of these incidents for many reasons, such as the patient profile, long waiting time, and overcrowding. We aimed to determine the characteristics and causes of violence toward emergency physicians. METHODS: The acts of violence toward emergency physicians over a one-year period were prospectively recorded. After a violent incident took place, a third party separately interviewed the physician exposed to the violent behavior and the perpetrator who displayed this behavior. We examined the perpetrator's reasons for violence, their demographic characteristics, and the medical complaints of patients involved in such events to determine the characteristics and causes of violence.RESULTS: Of the violent acts investigated, 85.1% were verbal, and most were directed toward male doctors by the young male relatives of the patients. More than half of the violent acts occurred within the 15 minutes of presentation to emergency service(60.5%) and at off-hours(69.4%). Concerning the health insurance, 20.4% of the cases were covered by the free green card system, and a small number of the perpetrators of violence lived in rural areas(38.2%). The most common reason for violent behavior was the patients' or their relatives' dissatisfaction with the examination or treatment method(38.2%).CONCLUSIONS: Appropriate communication should be established with the patients, and they should be adequately informed about the treatments and interventions to be performed in order to prevent possible acts of violence.

Does shifting to professional emergency department staffing affect the decision for chest radiography?

BACKGROUND: The study aims to determine whether shifting to professional emergency department(ED) teams leads to a higher rate of radiologic workup.METHODS: We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1(G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013(all patients were examined by an internal medicine specialist);group 2(G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019(all patients were examined by an emergency physician).RESULTS: The chest X-ray(CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR(38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found(47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1.CONCLUSIONS: Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.

Predictive Score for Pulmonary Ultrasound and Factors Associated to Mortality and Hospitalization during the Covid-19 Pandemic

Pulmonary ultrasound is a non-invasive bedside resource that has showed to be useful for the assessment of patients presenting with respiratory insufficiency as well as the diagnosis of several pleural and other pulmonary pathologies. The pulmonary ultrasound score (LUS) is a semi quantitative scale that measures the loss of pulmonary aeration cause by many pathologic conditions. Our primary objective was to describe factors associated to death and hospitalization in patients aged 16 or older that were admitted to the emergency department (ED) with signs or symptoms of COVID-19 infection through the diagnosis of viral pneumonia with pulmonary ultrasound (PU). It was a cohort retrospective study through a one-year period. Emergency physicians performed lung ultrasounds and calculated LUS. Results: 672 patients suspected of COVID-19 infection with a PU finding of viral pneumonia were included. 495 patients had a positive COVID-19 PCR test, 73.6% of the population. 258 patients presented with high probability of COVID-19 pneumonia following the patterns in PU. 55% were male with a median age of 45 years old. The average LUS score at admission was 8. Global hospitalization rate was 51.5%, 7.5% were admitted to the ICU. Patients with a LUS > 10 had a mortality of 6%, and patients admitted to the ICU had a 50% mortality rate. They presented with an average LUS score at admission of 15.2. Conclusions: LUS was a good predictor of death, hospitalization to general ward or ICU of patients with COVID-19 admitted from the emergency department.