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Background: The increasing awareness of the emotional consequences of emergency cesarean deliveries (C-sections) highlights their substantial role in fostering postpartum post-traumatic stress disorder (PTSD). This systematic review and meta-analysis aim to evaluate the prevalence and determinants of PTSD following emergency C-sections, as well as the implications of these events on maternal mental health and welfare., Methods: Undertaking extensive searches of Scopus, PubMed, PsycINFO, and Google Scholar, we have incorporated studies published from 2013 onwards that examined the occurrence of PTSD following emergency C-sections. Our primary focus was on the prevalence of PTSD at 6 weeks and up to 12 months postpartum. To evaluate the quality of these studies, we employed the Newcastle-Ottawa Scale (NOS) and the CEBM Critical Appraisal Tools., Findings: We included a total of 10 studies with 4,995 participants. The prevalence of PTSD following emergency C-sections ranged from 2.2 to 41.2%, compared to 0-20% in elective cesarean sections. A meta-analysis revealed a significant rise in the number of people with PTSD in the emergency C-section group compared to the elective C-section group six weeks after giving birth (OR = 2.74; 95% CI = 1.13 to 6.64; p = 0.03) and six weeks to 12 months later (OR = 3.68; 95% CI = 2.63 to 5.15; p < 0.00001). The emergency C-section group also had a higher PTSD prevalence compared to vaginal birth six weeks to 12 months after birth (OR 3.16; 95% CI 1.51 to 6.60; p = 0.02). Risk factors included poor social support, maternal and neonatal complications, and prior psychiatric history., Conclusions: Emergency C-sections are significantly associated with an increased risk of postpartum PTSD, necessitating targeted psychological support and interventions. Future research should aim for standardized diagnostic criteria and explore the long-term psychological outcomes of emergency C-sections., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings., Methods: Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05., Results: A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65)., Conclusion: This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making., (Copyright © 2021. Published by Elsevier Inc.)

In 2018, approximately 2.8 million passengers flew in and out of U.S. airports per day. Twenty-four to 130 in-flight medical emergencies are estimated to occur per 1 million passengers; however, there is no internationally agreed-upon recording or classification system. Up to 70% of in-flight emergencies are managed by the cabin crew without additional assistance. If a health care volunteer is requested, medical professionals should consider if they are in an appropriate condition to render aid, and then identify themselves to cabin crew, perform a history and physical examination, and inform the cabin crew of clinical impressions and recommendations. An aircraft in flight is a physically constrained and resource-limited environment. When needed, an emergency medical kit and automated external defibrillator are available on all U.S. aircraft with at least one flight attendant and a capacity for 30 or more passengers. Coordinated communication with the pilot, any available ground-based medical resources, and flight dispatch is needed if aircraft diversion is recommended. In the United States, medical volunteers are generally protected by the Aviation Medical Assistance Act of 1998. There is no equivalent law governing international travel, and legal jurisdiction depends on the patient's and medical professional's countries of citizenship and the country in which the aircraft is registered.

Introduction: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system., Methods: This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit., Results: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system., Conclusion: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.

School nurses' experienced barriers and benefits with perceptions of self-efficacy are important factors to consider for program implementation in the school setting. Little research has been done in the area of automated external defibrillator (AED) program implementation by the school nurse for the treatment of sudden cardiac arrest. The purpose of this study was to identify benefits of and barriers to AED program implementation in public schools and measure school nurses' self-efficacy related to their role as a change agent in program implementation. Results revealed that school nurses are functioning with a high level of self-efficacy in their ability to influence major health-care decisions in the school setting, and despite barriers, AED program implementation is considered beneficial and a necessary component of emergency care.

Introduction: Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India., Methods: This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages., Results: Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year., Conclusion: This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources., Competing Interests: The authors have declared that no competing interests exist.

Background: Given the sudden and unexpected nature of an emergency caesarean section (EmCS) coupled with an increased risk of psychological distress, it is particularly important to understand the psychosocial outcomes for women. The aim of this systematic literature review was to identify, collate and examine the evidence surrounding women's psychosocial outcomes of EmCS worldwide., Methods: The electronic databases of EMBASE, PubMed, Scopus, and PsycINFO were searched between November 2017 and March 2018. To ensure articles were reflective of original and recently published research, the search criteria included peer-reviewed research articles published within the last 20 years (1998 to 2018). All study designs were included if they incorporated an examination of women's psychosocial outcomes after EmCS. Due to inherent heterogeneity of study data, extraction and synthesis of both qualitative and quantitative data pertaining to key psychosocial outcomes were organised into coherent themes and analysis was attempted., Results: In total 17,189 articles were identified. Of these, 208 full text articles were assessed for eligibility. One hundred forty-nine articles were further excluded, resulting in the inclusion of 66 articles in the current systematic literature review. While meta-analyses were not possible due to the nature of the heterogeneity, key psychosocial outcomes identified that were negatively impacted by EmCS included post-traumatic stress, health-related quality of life, experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the most commonly examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptoms and diagnosis., Conclusions: EmCS was found to negatively impact several psychosocial outcomes for women in particular post-traumatic stress. While investment in technologies and clinical practice to minimise the number of EmCSs is crucial, further investigations are needed to develop effective strategies to prepare and support women who experience this type of birth.

Objectives: To evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers., Methods: A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively., Results: Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty., Conclusion: The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals' preferred outcomes could improve person-centred care., Prospero Registration Number: CRD42018107050., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary., Methods: We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses., Results: Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers., Conclusions: In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

Background: Measuring patient satisfaction has become an important parameter of the continuous quality assessment and improvement in anaesthesia services. The aim of this study was to assess the level of patient satisfaction with perioperative anaesthesia care and to determine the factors that influence satisfaction., Method: This study is an cross sectional design, conducted on 470 patients who underwent different types of surgeries at two National Referral Hospitals in Asmara, Eritrea between January and March of 2018. Patients were interviewed 24 h after the operation using a Tigrigna translated Leiden Perioperative Care Patient Satisfaction questionnaire (LPPSq). Descriptive and inferential analysis were made using SPSS (version 22). Statistical significance level was set at P < 0.05., Results: The overall satisfaction score was 68.8%. Less fear and concern was observed among patients with satisfaction scores of 87.5%. Staff-patient relationship satisfaction score was 75%. Patients were least satisfied with information provision (45%). Multivariable analysis revealed that satisfaction of patients who did surgery at Halibet hospital is significantly higher (p < 0.001) than those patients who did at Orotta hospital. Moreover, those patients who did elective surgery had higher level of satisfaction that those who did emergency surgery (p < 0.001)., Conclusion: Moderate level of satisfaction was observed among the patients. Generally, the study emphasized that the information provision about anesthesia and surgery was low. Patients described better staff-patient relationship and low fear and concern related to anesthesia and surgery was observed.

Background: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit., Methods: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes., Results: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL., Conclusions: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Aims: To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care., Methods: In-depth semi-structured interviews with 27 adolescents (16 males; aged 14-17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis., Results: Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves., Conclusions: Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence., Trial Registration: ISRCTN Number: 45300218., Competing Interests: The authors have declared that no competing interests exist.

Background and Aims: Patients who leave Emergency Department before physician's visit (LWBS) or during treatment (LDT) represent a useful indicator of the emergency care's quality. The profile of patients LWBS was described: they are generally males, young, with lower urgency triage allocation and longer waiting time. They have a greater risk of ED re-admission compared to discharged patients, but effect on hospitalization and mortality are more controversial. The aims of this study are to identify determinants and adverse short term outcomes for LWBS and LDT patients., Methods: This is a retrospective cohort study that include all ED visits of LWBS, LDT and discharged patients in 2015 in the Lazio region, Central Italy. Determinants of LWBS or LDT were selected from gender, age, citizenship, residence area, triage category, chronic comorbidities, number of uncompleted ED visit in the previous year, mode of arrival in ED, time-band, day of the week, waiting time and ED crowding, using a multi-level logistic regression. A multivariate logistic regression was used to test if LWBS or LDT have a greater risk of short term adverse outcome compared to discharged patients., Results: The cohort consists in 835,440 visits in ED, 86.8% subjects visited and discharged, 8.9% subjects are LWBS patients and 4.3% LDT. LWBS and LDT patients are mainly young, males, with a less severe triage, with long waiting times in ED. Moreover, ED crowding and leaving ED before physician's visit in the previous year are risk factors of self-discharging. LWBS and LDT patients have a higher risk of readmission (LWBS: OR = 4.63, 95%CI 4.5-4.7; OR = 2.89, 95%CI 2.8-2.9; LDT: OR = 3.12, 95%CI 3-3.2; OR = 2.25, 95%CI2.2-2.3 for readmissions within 2 and 7 days respectively) and hospitalization (LWBS: OR = 3.65, 95%CI 3.4-3.9; OR = 2.25, 95%CI 2.1-2.4; LDT: OR = 3.96, 95%CI 3.6-4.3; OR = 2.62, 95%CI 2.4-2.8 for hospitalization within 2 and 7 days respectively). Furthermore, we find a mortality excess of risk for LWBS patients compared to the reference group (OR = 2.56, 95%CI1.6-4.2; OR = 1.7, 95%CI 1.3-2.2 within 2 and 7 days respectively)., Conclusions: Determinants of LWBS confirmed what already known, but LDT patients should be further investigated. There could be adverse health effects for people with LWBS and LDT behaviour. This could be an issue that the Regional Health System should deal with., Competing Interests: The authors have declared that no competing interests exist.

Aims and Objective: To explore patients' experiences of acute dyspnoea, physical functioning and perspectives on course of illness prior to admission to the emergency department., Background: Many emergency admissions are considered unnecessary and avoidable. In this perspective, it seems relevant to gain insight into the patients' perspective on acute dyspnoea and the need for emergency admission. However, only few studies have investigated reasons for emergency admission from a patient perspective., Design: A qualitative study was conducted with semi-structured interviews among six patients previously admitted to the emergency department due to dyspnoea. Data collection and analysis were carried out according to Kvale & Brinkmann using meaning condensation., Findings: Dyspnoea was experienced as an unpleasant breathlessness in the form of pain or suffocation, which limited usual physical activities, negatively impacting on quality of life. Self-management strategies such as medication, breathing exercises, distraction from breathing, and mental and physical relaxation in general were used to avoid hospital admission. The chronically ill patients saw the following ways to alternate course of disease to avoid admissions to the emergency department: easier access to specialised emergency medical care, medical supplies in the patient's home and making existing physical exercise programmes more accessible and interesting., Conclusion and Relevance to Clinical Practice: It would be relevant to further investigate whether prehospital interventions may remedy acute dyspnoea among chronically ill patients, and whether such interventions are cost-effective., (© 2018 John Wiley & Sons Ltd.)

Question: What are staff and patients' perceptions of physiotherapists working in the emergency department (ED)?, Design: Systematic review of qualitative studies., Participants: Staff working in EDs and patients presenting to the ED and managed by ED physiotherapists., Outcome Measures: Perceptions of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction, grouping (codes), and abstraction of findings., Results: Eight studies, which had sought the perceptions of 138 patients and 122 ED staff members, were included. Three main themes emerged: role of physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education, non-pharmacological pain management and activity resumption, especially through exercise therapy. Having broad knowledge to assess and treat different health conditions was seen as facilitating the work of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal communication skills. ED staff expressed concerns regarding the additional time that physiotherapists spent with patients. Some patients felt that performing exercises in the ED was inappropriate and painful., Conclusions: ED physiotherapists were mostly well accepted by patients and ED staff, and their work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira GE, Traeger AC, O'Keeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy 64: 229-236]., (Copyright © 2018 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Introduction: This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management., Methods: This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant., Results: Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49)., Conclusion: The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Alcohol misuse is a well-known risk factor for suicide however, the relationship between alcohol-related hospital admission and subsequent risk of death from suicide is unknown. We aimed to determine the risk of death from suicide following emergency admission to hospital with an alcohol-related cause., Methods: We established an electronic cohort study of all 2,803,457 residents of Wales, UK, aged from 10 to under 100 years on 1 January 2006 with six years' follow-up. The outcome event was death from suicide defined as intentional self-harm (ICD-10 X60-84) or undetermined intent (Y10-34). The main exposure was an alcohol-related admission defined as a 'wholly attributable' ICD-10 alcohol code in the admission record. Admissions were coded for the presence or absence of co-existing psychiatric morbidity. The analysis was by Cox regression with adjustments for confounding variables within the dataset., Results: During the study follow-up period, there were 15,546,355 person years at risk with 28,425 alcohol-related emergency admissions and 1562 suicides. 125 suicides followed an admission (144.6 per 100,000 person years), of which 11 (9%) occurred within 4 weeks of discharge. The overall adjusted hazard ratio (HR) for suicide following admission was 26.8 (95% confidence interval (CI) 18.8 to 38.3), in men HR 9.83 (95% CI 7.91 to 12.2) and women HR 28.5 (95% CI 19.9 to 41.0). The risk of suicide remained substantial in subjects without known co-existing psychiatric morbidity: HR men 8.11 (95% CI 6.30 to 10.4) and women HR 24.0 (95% CI 15.5 to 37.3). The analysis was limited by the absence in datasets of potentially important confounding variables and the lack of information on alcohol-related harm and psychiatric morbidity in subjects not admitted to hospital., Conclusion: Emergency alcohol-related hospital admission is associated with an increased risk of suicide. Identifying individuals in hospital provides an opportunity for psychosocial assessment and suicide prevention of a targeted at-risk group before their discharge to the community.

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group., (© 2017 by the Society for Academic Emergency Medicine.)

Background: Decision delivery interval (DDI) is the time line between a decision to conduct an emergency caesarean section and actual delivery of the baby. Prolong DDI constitute a third phase delay in provision of emergency obstetric care. Intervention designed to minimize DDI are vital, in attempt to prevent maternal morbidity and neonatal morbidity and mortality. The feasibility and practicability of the recommended DDI in recent studies have been questioned especially in limited resource setting and therefore the objective of our study was to determine the DDI and its associated fetalmaternal outcomes at a tertiary referral hospital in Tanzania., Methods: This was a retrospectivecross-sectional study of inpatient cases who underwent emergency caesarean section from January to September 2014. Data were collected from birth registry and case files of patients. Data analysis was performed using statistical package for social science (SPSS) version 22.0. Odds ratio (ORs) and 95% confidence interval for maternal and fetal outcomes associated with DDI were estimated using Logistic regression models. A p-value of less than 5% was considered statistically significant., Results: A total of 598 women who underwent emergency caesarean section were recruited. The median Decision Delivery Interval was 60 min [IQR 40-120]. Only 12% were operated within 30 min from decision time. Shortest DDI was seen in patients with Cephalopelvic Disproportion (CPD) and uterine rupture (40 min and 45.5 min) as compared to other conditions. Cases with impending uterine rupture, cord prolapse, APH and fetal distress showed to have shorter DDI. There was no significant association between DDI and neonatal transfer,1st and 5 th minute Apgar score, maternal blood loss (OR: 5.79; 95% CI 0.63-1.64) and hospital stay (OR: 1.02; 95% 0.63-1.64)., Conclusions: Contrary to the recommended DDI by ACOG & AAP of 30 min is not feasible in our setting, time frame of 75 min could be acceptable but clinical judgment is required to assess on the urgency of caesarean section in order to prevent maternal and neonatal morbidity and mortality.

Aims and Objectives: To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department., Background: Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration., Design: Descriptive exploratory study using nonparticipatory observation., Methods: Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis., Results: Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take., Conclusions: Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration., Relevance to Clinical Practice: This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research., (© 2017 John Wiley & Sons Ltd.)

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers., (© 2017 American Society for Healthcare Risk Management of the American Hospital Association.)

Objective: To examine parental expectations and beliefs about diagnosis and management of pediatric concussion., Study Design: We conducted a cross-sectional web-based survey of a nationally representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and χ2 statistics were used for bivariate analysis., Results: Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child's usual provider or wait at home to "definitely expect" imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%)., Conclusions: Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: This study profiles an innovative approach to capture patient satisfaction data from emergency department (ED) patients by implementing an electronic survey method. This study compares responders to nonresponders., Background: Our hypothesis is that the cohort of survey respondents will be similar to nonresponders in terms of the key characteristics of age, gender, race, ethnicity, ED disposition, and payor status., Methods: This study is a cross-sectional design using secondary data from the database and provides an opportunity for univariate analysis of the key characteristics for each group. The data elements will be abstracted from the database and compared with the same key characteristics from a similar sample from the database on nonresponders to the ED satisfaction survey., Findings: Age showed a statistically significant difference between responders and nonresponders. Comparison by disposition status showed no substantial difference between responders and nonresponders. Gender distribution showed a greater number of female than male responders. Race distribution showed a greater number and response by white and Asian patients as compared with African Americans. A review of ethnicity showed fewer Hispanics responded. An evaluation by payor classification showed greater number and response rate by those with a commercial or Workers Comp payor source. The response rate by Medicare recipients was stronger than expected; however, the response rate by Medicaid recipients and self-pay could be a concern for underrepresentation by lower socioeconomic groups. Finally, the evaluation of the method of notification showed that notification by both e-mail and text substantially improved response rates., Conclusion: The evaluation of key characteristics showed no difference related to disposition, but differences related to age, gender, race, ethnicity, and payor classification. These results point to a potential concern for underrepresentation by lower socioeconomic groups. The results showed that notification by both e-mail and text substantially improved response rates.

This study aimed to characterize the perspectives of health professionals who care for children with autism spectrum disorder (ASD) in the emergency department (ED) and to determine what strategies could optimize care. Ten physicians and twelve nurses were interviewed individually. Questions related to experiences, processes, clinical decision-making and outcomes of children with ASD recently seen in the ED. Interviews were audio recorded, transcribed, and analyzed using a qualitative framework. Participants identified factors that facilitated effective care, including communication strategies, parental involvement and teamwork. Barriers identified included child characteristics, the ED environment, and competing demands. Recommendations included additional staff training and stakeholder engagement. However, making accommodations was often described as being at odds with how the ED functioned, with implications for future service planning.

Background: Emergency postpartum hysterectomy (EPH) is usually considered the final resort for the management of postpartum hemorrhage (PPH). The aim of this observational study was to identify the risk factors for EPH, to evaluate the ability of EPH to stop bleeding and, finally, to estimate its psychological impact., Methods: This was a retrospective analysis of postpartum hysterectomy in all patients with PPH admitted between 2004 and 2011 to Lariboisière Hospital. We compared women for whom EPH was successful and those who required an advanced interventional procedure (AIP) to stop the bleeding despite hysterectomy. We also evaluated the severe PPH (SPPH) score in this particular setting. The psychological impact of emergency hysterectomy was also assessed., Results: A total of 44 hysterectomies were performed among 869 cases of PPH. Twenty were successful, while an additional AIP was required in 22 others (50%). Prothrombin time<50% and a shorter interval between the onset of PPH and hysterectomy were independently associated with the need for an additional AIP. The area under the ROC curve of the SPPH score to predict the need for another AIP was 0.738 (95% confidence interval 0.548-0.748). Furthermore, 64% of the hysterectomized patients suffered from post-traumatic stress disorder., Conclusion: Failure of postpartum hysterectomy to control bleeding was frequent, and it was associated with persistence of coagulopathy. Hysterectomy in this context had important psychological impacts., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Although patients' families want to be invited to the bedside of hospitalized loved ones during crisis events, little is known about patients' perceptions of family presence., Objective: To explore adult inpatients' perceptions of family presence during resuscitation, near-resuscitation, and unplanned invasive cardiac procedures shortly after the life-threatening event., Methods: In this qualitative study, data were collected by interviews at least 13 hours after a crisis event and before hospital discharge. Data were audio recorded, transcribed, and analyzed for themes., Results: From the bedside interviews (N = 48), the overarching theme of "being there" was explained more specifically as "being there is beneficial," "being there is hard," "families in the way," and "desire for control." Most participants preferred family presence, although preferences varied with types of crisis events, patients' predictions of family members' responses, and the nature of family relationships. New perspectives emerged about patients' decision making related to family presence., Conclusions: This study extends existing knowledge about factors that influence the decision-making processes of hospitalized patients regarding family presence during a crisis event. Health care professionals can provide support as patients ponder difficult decisions about who to have present and can reduce patients' fears that families might interfere with the life-saving efforts., (©2015 American Association of Critical-Care Nurses.)

Background: While Asia has the dubious distinction of being the world's most natural disaster-prone area, disaster nursing education and training are sparse in many Asian countries, especially China where this study took place., Objective: To explore the earthquake disaster experiences of Chinese nurses and develop a substantive theory of earthquake disaster nursing that will help inform future development of disaster nursing education., Design: A qualitative study employing grounded theory, informed by symbolic interactionism., Participants and Setting: Fifteen Chinese registered nurses from five hospitals in Jiangxi Province who undertook relief efforts after the 2008 Wenchuan Earthquake., Methods: Data were collected in 2012-2013 in digitally-recorded, semi-structured, in-depth interviews and reflective field notes, and analyzed using Glaser's grounded theory method., Results: Participants were unprepared educationally and psychologically for their disaster work. Supporting the emergent theory of "working in that terrible environment", was the core category of "turning into a strong nurse", a process of three stages: "going to the disaster"; "immersing in the disaster"; and "trying to let disaster experiences fade away". The participants found themselves thrust in "terrible" scenes of destruction, experienced personal dangers and ethical dilemmas, and tried the best they could to help survivors, communities and themselves, with limited resources and confronting professional work., Conclusions: Our rich findings confirm those of other studies in China and elsewhere, that attention must be paid to disaster education and training for nurses, as well as the mental health of nurses who work in disaster areas. Emergent theory helps to inform nurse educators, researchers, leaders and policy makers in China, and elsewhere in developing strategies to better prepare nurses for future disasters, and assist communities to prepare for and recover after earthquake disasters., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The Centers for Disease Control and Prevention estimated that up to 88 million H1N1 influenza cases, 398,000 hospitalizations, and up to 18,050 related deaths, including significant racial and ethnic disparities, occurred between April 2009 and March 13, 2010. The Food and Drug Administration (FDA) approved emergency use authorizations (EUAs), which allowed the distribution of unapproved drugs or the off-label use of approved drugs. In late 2009, peramivir was granted an EUA for patients with severe disease. This study examined factors associated with willingness to take peramivir., Methods: In 2010 we conducted a nationally representative survey with 2079 respondents randomly drawn from the Knowledge Networks research panel. Our completion rate was 56%. Respondents received information about peramivir from a fact sheet and then answered questions about their willingness to take the drug., Results: Overall, 48% of participants indicated that they would probably or definitely take peramivir. Seventy-nine percent definitely would take the drug if their doctor recommended it and there were no alternative treatments. There were significant racial differences in willingness. The term experimental to refer to the drug decreased willingness to accept peramivir among both whites and blacks., Conclusions: Trust in the FDA was important for peramivir acceptance. Particular care must be taken to ensure that patients and their families understand the complex nature of EUA drugs. Lessons learned can inform communication about future EUAs. (Disaster Med Public Health Preparedness. 2015;9:166-174).

Disasters require well trained nurses but disaster nursing education is very limited in China and evidence is urgently required for future planning and implementation of specialized disaster education. This describes the themes arising from narratives of Chinese registered nurses who worked in disaster relief after two major earthquakes. In-depth interviews were held with 12 registered nurses from Hubei Province. Riessman's narrative inquiry method was used to develop individual stories and themes, and socio-cultural theory informed this study. Five themes emerged: unbeatable challenges; qualities of a disaster nurse; mental health and trauma; poor disaster planning and co-ordination; and urgently needed disaster education. Participants were challenged by rudimentary living conditions, a lack of medical equipment, earthquake aftershocks, and cultural differences in the people they cared for. Participants placed importance on the development of teamwork abilities, critical thinking skills, management abilities of nurses in disasters, and the urgency to build a better disaster response system in China in which professional nurses could more actively contribute their skills and knowledge. Our findings concur with previous research and emphasize the urgency for health leaders across China to develop and implement disaster nursing education policies and programs., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Aim: The aim of this study is to directly compare published prediction tools with triage nurse (TN) predictions within a defined paediatric population., Method: A prospective observational study carried out over a week in May 2010 in the Emergency Department (ED) at Princess Margaret Hospital for Children in Perth, Western Australia. TN predicted which patients would be admitted to hospital at the time of ED presentation. Data required for the other prediction tools (paediatric early warning score (PEWS); triage category and the Pediatric Risk of Admission Score (PRISA) and PRISA II were obtained from the notes following the patient's ED attendance., Results: A total of 1223 patients presented during the study week, 91 patients were excluded and a total of 946 patients (83.6%) had TN predictions and were included in the analysis. TN predictions were compared against a PEWS ≥ 4, triage category 1, 2 and 3, PRISA ≥ 9 and PRISA II ≥ 2. TNs had the highest prediction accuracy (87.7%), followed by an elevated PEWS (82.9%), triage category of 1, 2, or 3 (82.9%). The PRISA and PRISA II score had an accuracy of 80.1% and 79.7%, respectively., Conclusion: When compared with validated prediction tools, the TN is the most accurate predictor of need to admit. This study provides valuable information in planning efficient flow of patients through the ED., (© 2012 The Authors. Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Introduction: Patients with chronic pain who frequent emergency departments present a challenge to health care providers. Mental health, substance abuse, and pain issues are difficult to distinguish in fast-paced clinical settings, and significant symptoms may remain unaddressed. This pilot study sought to determine whether electronically delivered screening tools measuring pain and mood could identify areas to target for improving emergency care., Methods: A prospective, descriptive pilot study used repeated measures of validated instruments to investigate the status of patients after their ED encounter. Persons with chronic pain not related to cancer and documented opioid use were recruited by nursing personnel after an ED encounter. Consenting participants (n = 52) were invited to perform an online survey that included self-reported measurements of pain intensity, pain interference, depression, subjective health, and health distress. The survey was repeated after 8 weeks., Results: The baseline survey was completed by 42.3% of 52 patients who provided consent (n = 22, 68.2% female). The mean pain severity score was 5.96 (SD 1.57) and the mean pain interference score was 7.52 (SD 1.81) using 0 to 10 scales of the Brief Pain Inventory. Personal Health Questionnaire Depression Scale ratings indicated that a major depressive disorder should be considered for 54% of the participants., Discussion: Online surveys delivered to patients with chronic pain detected unmet needs for depression and persisting high levels of pain interference after ED encounters. Adding mood-specific screening tools to pain assessments may be necessary in clinical settings to identify depression and refer for appropriate treatment., (Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Objective: Dentofacial emergencies are a common presentation to the emergency department (ED) but there is little recent data on physicians' knowledge, confidence and attitudes in handling these cases., Method: A questionnaire was administered to 103 ED physicians. The sample was primarily drawn from London hospitals as well a smaller contribution from around the UK and included physicians with a range of experience and at different grades., Results: The majority of the 102 participants (76.5%) did not receive any formal training in managing dentofacial emergencies. The percentage of participants who were happy to manage common dentofacial emergencies is as follows: dental trauma (20.4%); major facial trauma (39.8%); interpreting facial X-rays (68.0%); and facial suturing (85.4%). When questioned 12.1% of the participants felt that ED physicians should be responsible for managing dental emergencies compared to 22.4% who felt that ED physicians should manage maxillofacial emergencies. Only 3.9% of the participants would opt to be treated by an ED doctor in the event of them presenting to the ED with a dental injury. The remaining 72.5% would prefer to be seen by a maxillofacial surgeon, 23.5% by a dentist and none of the participants opted to be seen by the emergency nurse practitioner., Conclusion: ED physicians do not feel confident in managing some dentofacial emergencies. This may be attributed to a lack of training in this area as well as exposure to these types of emergencies. There is a need for greater awareness, validated guidelines and training resources for ED physicians to treat dentofacial emergencies as well more research in this field of emergency medicine., (© 2011 John Wiley & Sons A/S.)

Background: Immediate management of traumatized teeth is often critical to the prognosis of the teeth. Most of the traumatic dental injuries occur at home, followed by school. There is a high probability that first aid would be given by lay people such as parents, teachers, or coaches. Knowledge of those people regarding emergency management of dental trauma is crucial for better prognosis., Aim: To investigate: (i) the knowledge of elementary school teachers regarding traumatic dental injuries to permanent teeth and emergency treatment, (ii) their source of information, and (iii) the demand for more education in dental trauma., Materials and Methods: A three-part questionnaire comprised of questions regarding demographic data, attitude, and knowledge about dental injuries was distributed to teachers in 12 elementary schools in the Tel-Aviv area, Israel., Results: The average knowledge score was 4.59 (in a scale of 0-10). Three individual predictors significantly improved the respondents' knowledge: being in the 35-49-year age group (P-value = 0.042), those who had children themselves (P-value = 0.002) and those who had previous experience with trauma (P-value = 0.049). There was no correlation between the demand for further education in dental trauma and knowledge score., Conclusions: The knowledge regarding management of traumatic dental injuries in a group of teachers in the Tel-Aviv area is inadequate. Educational programs as well as addition to the curriculum are necessary to improve their emergency management of traumatic dental injuries and provide better protection to the students., (© 2011 John Wiley & Sons A/S.)

Background: Abdominal pain is one of the most frequent reasons for seeking care in an emergency department. Surveys have shown that patients are not satisfied with the pain management they receive. Reasons for giving inadequate pain management may include poor knowledge about pain assessment, myths concerning pain, lack of communication between the patient and healthcare professional, and organizational limitations., Objectives: The aim of the study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated intravenous opioid analgesic compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time, and (e) patients' perceptions of the quality of care in pain management., Design: A quasi-experimental design with ABA phases was used., Setting: The study was conducted in an emergency department at a Swedish university hospital., Participants: Patients with abdominal pain seeking care in the emergency department were invited to participate. A total of 50, 100 and 50 patients, respectively, were included for the three phases of the study. The inclusion criteria were: ongoing abdominal pain not lasting for more than 2 days, ≥18 years of age and oriented to person, place and time. Exclusion criteria were: abdominal pain due to trauma, in need of immediate care and pain intensity scored as 9-10., Methods: The patients' perceptions of the quality of care in pain management in the emergency department were evaluated by means of a patient questionnaire carried out in the three study phases. The intervention phase included education, nursing assessment protocol and a range order for analgesic., Results: The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in significant improvement in frequency of receiving analgesic and a reduction in time to analgesic. Patients perceived lower pain intensity and improved quality of care in pain management., Conclusions: The intervention improved the pain management in the emergency department. A structured nursing assessment could also affect the patients' perceptions of the quality of care in pain management in the emergency department., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: In the acute trauma caused by intimate partner violence (IPV), the emergency department (ED) and its staff are often the first contact for women. The failure to intervene in IPV situations may contribute to further injury and health problems for women, as well as to frequent visits to the ED., Aims: The aims of this study is to describe the history of IPV with its health consequences for women when seeking care for their acute injuries and what kinds of care experiences had the women had when visiting EDs., Methods: Data were collected via questionnaires from 35 women and after that seven semi-structured interviews were conducted. The data were analyzed using quantitative and qualitative methods., Results: Among the women the lifetime prevalence of physical IPV was 94%. Ninety-seven percent of past and 56% of acute cases of physical violence were accompanied by psychological violence. The surveyed women highlighted individual needs for care, including appropriate medical care of injuries, and psychological and tangible support. The women worried about their children and partners and regarded supporting the whole family as important., Conclusion: There is a need for ED professionals to develop family-oriented services, and a need for further training and research on how to deal with women exposed to IPV., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Twenty-one women, who were treated for postpartum haemorrhage by embolisation of the uterine artery, filled in a series of questionnaires. The questionnaires assessed personality characteristics, illness perceptions, coping and quality of life (QoL). The women also made drawings of their uterus. The results suggest that women who experience emergency embolisation have good QoL at follow-up.

Aim: The aim of this study was to assess the knowledge of Mangalore mothers regarding dental trauma., Methods: A questionnaire inquiring about mother's knowledge on dental trauma was distributed to 500 working and non-working mothers via their children attending two primary schools in the Mangalore city., Results: Around 68.5% of the mothers were aware of the management of dental trauma. Of the working mothers, 72% were aware of the management of dental trauma while 65% of the non-working mothers were aware. When asked about saving the avulsed tooth, 36% of mothers said that the avulsed tooth can be saved. Regarding mouth guards, 54.5% of the mothers said that they aware of the use of mouth guards to prevent traumatic injuries to the teeth. Of the working mothers 72% knew that mouth guards are useful in the prevention of dental trauma while 37% of the non-working mothers have this knowledge; 68% of the mothers would take the child to the dentist following tooth injury whereas 17% of the mothers would use an emergency kit. Chi-square test and logistic regression analysis indicated a significant difference between the responses of working and the non-working mothers with regard to mouth guard knowledge and recommendation (P-value 0.001)., Conclusion: Most of the mothers were graduates and were aware of the emergency management of dental trauma. The working mothers had better knowledge and awareness regarding mouth guards (72%) when compared with non-working mothers (37%)., (© 2010 John Wiley & Sons A/S.)

Principles: Women of reproductive age with cancer fear for their childbearing potential as a result of the cancer itself and chemo- and/or radiation-therapy., Methods: Starting in 2006, a dedicated task force was set up at Lausanne University Hospital (CHUV) to handle all cancer and fertility issues and, in certain cases, offer access to emergency assisted reproductive technologies (ART) to preserve further childbearing options. Help provided by the task force was offered within a multidisciplinary framework encompassing psychological counselling offered to each patient or couple., Results: We report here the salient points of the experience gained through dedicated psychological counselling offered to cancer patients concerned about their future fecundity. This was done with the intention of underscoring the most clinically relevant lessons learned through our experience at CHUV., Conclusions: The specific 'cancer and fertility' counselling instituted at CHUV offers support for young women or couples confronted with stressful cancer and fertility issues. This type of specific counselling, the resource counselling, appears to be a particularly appropriate tool for patients abruptly involved in difficult decision-making processes under time constraints and thus extremely vulnerable. The personal feedbacks from the patients also confirm the importance of offering specific counselling and timely psychological support of the type reported here to all women of reproductive age before starting chemo- and/or radiation-therapy.

One in 6 pregnancies is lost before the 20th week of gestation and the psychological impacts of this loss are frequently unaddressed while attention is focused on immediate physiological needs. To improve the comprehensive care provided to women experiencing pre-20-week loss, an evidence-based intervention protocol was developed to provide emotional support to these women in the immediate aftermath of the loss. The protocol was tested using a sample of 40 women who experienced a pre-20-week perinatal loss and were being treated in a large county emergency center. Twenty randomly selected women received the intervention protocol while another 20 women received the usual standard of care. Both groups completed the Perinatal Grief Scale during a routine 2-week follow-up visit. The results indicated that the intervention was effective in ameliorating the degree of despair in women experiencing an early pregnancy loss. Women receiving the protocol expressed feelings of being supported and cared for by the staff. Secondary benefits were an increased collaboration among health care professionals, development of an environment of empathy, and a change in the culture of belief that these women needed only physical care. Results indicate a need for a support protocol for all women experiencing loss regardless of gestational age.

The aim of this study was to systematically review qualitative literature published between 1990 and 2006 exploring the patient experience within the emergency department (ED) with the intent of describing what factors influence the patient experience. Twelve articles were retrieved following combination of key words using five databases. The overarching categories developed from this integration of literature were; emotional impact of emergency, staff-patient interactions, waiting, family in the emergency department, and emergency environment. The patient experience issue given most emphasis by the articles under review was the caring or lack of caring regarding the patients' psychosocial and emotional needs. This was in contrast to the culture of the ED which emphasised "medical-technical" skill and efficiency. Satisfaction studies need to understand many factors and influences, qualitative methodologies have the ability to do so., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Background: : This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality., Methods: : Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD., Results: : A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021)., Conclusion: : The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated., (Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)