Search

Abstract Background Medical staff are regularly confronted with workplace violence (WPV), which poses a threat to the safety of both staff and patients. Structured de-escalation training (DET) for Emergency Department (ED) staff has been shown to positively affect the reporting of WPV incidents and possibly reduce its impact. This study aimed to describe the development of incidence rates, causes, means, targets, locations, responses, and the time of WPV events. Additionally, it explored the effect of the staff trained in DET on the objective and subjective severity of the respective WPV events. Methods In a retrospective, single-center cohort study, we analyzed ten years of WPV events using the data of Staff Observation Aggression Scale-Revised (SOAS-R) score (ranging from 0 to 22) in a tertiary ED from 2014 to 2023. The events were documented by ED staff and stored in the electronic health record (EHR). Results Between 2014 and 2023, 160 staff members recorded 859 incidents, noting an average perceived severity of 5.78 (SD = 2.65) and SOAS-R score of 11.18 (SD = 4.21). Trends showed a non-significant rise in incident rates per 10,000 patients over time. The WPV events were most frequently reported by nursing staff, and the cause of the aggression was most often not discernible (n = 353, 54.56%). In total, n = 273 (31.78%) of the WPV events were categorized as severe, and the most frequent target of the aggressive behavior was the staff. WPV events occurred most frequently in the traumatology section and the detoxification rooms. While the majority of events could be addressed with verbal interventions, more forceful interventions were performed significantly more often for higher severity WPV events. More WPV events occurred during off-hours and were of a significantly higher objective and subjective severity. Overall, the presence of staff with completed DET led to significantly higher SOAS-R scores and higher perceived severity. Conclusion The findings underline the relevance of WPV events in the high-risk environment of an ED. The analyzed data suggest that DET significantly fostered the awareness of WPV. While most events can be addressed with verbal interventions, WPV remains a concern that needs to be addressed through organizational measures and further research.

Abstract Background Increasing numbers of patients treated in the emergency departments pose challenges to delivering timely and high-quality care. Particularly, the presentation of patients with low-urgency complaints consumes resources needed for patients with higher urgency. In this context, patients with non-specific back pain (NSBP) often present to emergency departments instead of primary care providers. While patient perspectives are well understood, this study aims to add a provider perspective on the diagnostic and therapeutic approach for NSBP in emergency and primary care settings. Methods In a qualitative content analysis, we interviewed seven Emergency Physicians (EP) and nine General Practitioners (GP) using a semi-structured interview to assess the diagnostic and therapeutic approach to patients with NSBP in emergency departments and primary care practices. A hypothetical case of NSBP was presented to the interviewees, followed by questions on their diagnostic and therapeutic approaches. Recruitment was stopped after reaching saturation of the qualitative content analysis. Reporting this work follows the consolidated criteria for reporting qualitative research (COREQ) checklist. Results EPs applied two different strategies for the workup of NSBP. A subset pursued a guideline-compliant diagnostic approach, ruling out critical conditions and managing pain without extensive diagnostics. Another group of EPs applied a more extensive approach, including extensive diagnostic resources and specialist consultations. GPs emphasized physical examinations and stepwise treatment, including scheduled follow-ups and a better knowledge of the patient history to guide diagnostics and therapy. Both groups attribute ED visits for NSBP to patient related and healthcare system related factors: lack of understanding of healthcare structures, convenience, demand for immediate diagnostics, and fear of serious conditions. Furthermore, both groups reported an ill-suited healthcare infrastructure with insufficiently available primary care services as a contributing factor. Conclusions The study highlights a need for improving guideline adherence in younger EPs and better patient education on the healthcare infrastructure. Furthermore, improving access and availability of primary care services could reduce ED visits of patients with NSBP. Trial registration No trial registration needed.

Abstract Background When stroke patients with suspected anterior large vessel occlusion (aLVO) happen to live in rural areas, two main options exist for prehospital transport: (i) the drip-and-ship (DnS) strategy, which ensures rapid access to intravenous thrombolysis (IVT) at the nearest primary stroke center but requires time-consuming interhospital transfer for endovascular thrombectomy (EVT) because the latter is only available at comprehensive stroke centers (CSC); and (ii) the mothership (MS) strategy, which entails direct transport to a CSC and allows for faster access to EVT but carries the risk of IVT being delayed or even the time window being missed completely. The use of a helicopter might shorten the transport time to the CSC in rural areas. However, if the aLVO stroke is only recognized by the emergency service on site, the helicopter must be requested in addition, which extends the prehospital time and partially negates the time advantage. We hypothesized that parallel activation of ground and helicopter transportation in case of aLVO suspicion by the dispatcher (aLVO-guided dispatch strategy) could shorten the prehospital time in rural areas and enable faster treatment with IVT and EVT. Methods As a proof-of-concept, we report a case from the LESTOR trial where the dispatcher suspected an aLVO stroke during the emergency call and dispatched EMS and HEMS in parallel. Based on this case, we compare the provided aLVO-guided dispatch strategy to the DnS and MS strategies regarding the times to IVT and EVT using a highly realistic modeling approach. Results With the aLVO-guided dispatch strategy, the patient received IVT and EVT faster than with the DnS or MS strategies. IVT was administered 6 min faster than in the DnS strategy and 22 min faster than in the MS strategy, and EVT was started 47 min earlier than in the DnS strategy and 22 min earlier than in the MS strategy. Conclusion In rural areas, parallel activation of ground and helicopter emergency services following dispatcher identification of stroke patients with suspected aLVO could provide rapid access to both IVT and EVT, thereby overcoming the limitations of the DnS and MS strategies.

Abstract Background Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations. However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable outcome for the patient. Case presentation During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The patient survived without any residues or neurological impairment. Conclusions This case demonstrates the potential deleterious effects of shortcomings in communication and deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case. Interestingly, this serious error may have saved the patient’s life, as it led to the development of a shockable rhythm. Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-shockable cardiac arrest was significant and possibly averted by the medication error.

Abstract Introduction Aphasia and neglect in combination with hemiparesis are reliable indicators of large anterior vessel occlusion (LAVO). Prehospital identification of these symptoms is generally considered difficult by emergency medical service (EMS) personnel. Therefore, we evaluated the simple non‐paretic‐hand‐to‐opposite‐ear (NPE) test to identify aphasia and neglect with a single test. As the NPE test includes a test for arm paresis, we also evaluated the diagnostic ability of the NPE test to detect LAVO in patients with suspected stroke. Methods In this prospective observational study, we performed the NPE test in 1042 patients with suspected acute stroke between May 2021 and May 2022. We analyzed the correlation between the NPE test and the aphasia/neglect items of the National Institutes of Health Stroke Scale. Additionally, the predictive values of the NPE test for LAVO detection were calculated. Results The NPE test showed a strong, significant correlation with both aphasia and neglect. A positive NPE test result predicted LAVO with a sensitivity of 0.70, a specificity of 0.88, and an accuracy of 0.85. Logistic regression analysis showed an odds ratio of 16.14 (95% confidence interval 10.82–24.44) for predicting LAVO. Conclusion The NPE test is a simple test for the detection of both aphasia and neglect. With its predictive values for LAVO detection being comparable to the results of LAVO scores in the prehospital setting, this simple test might be a promising test for prehospital LAVO detection by EMS personnel. Further prospective prehospital validation is needed.

Background: Since 2021, international guidelines for cardiopulmonary resuscitation recommend the implementation of so-called “life-saving systems”. These systems include smartphone alerting systems (SAS), which enable dispatch centres to alert first responders via smartphone applications, who are in proximity of a suspected out-of-hospital cardiac arrest (OHCA). However, the effect of SAS on survival remains unknown. Aim: The aim is to assess the rate of survival to hospital discharge in adult patients with OHCA not witnessed by emergency medical services (EMS): before and after SAS implementation. Design: Multicentre, prospective, observational, intention-to-treat, pre–post design clinical trial. Population: Adults (aged ≥ 18 years), OHCA not witnessed by EMS, no traumatic cause for cardiac arrest, cardiopulmonary resuscitation initiated or continued by EMS. Setting: Dispatch-centre-based. Outcomes: Primary: survival to hospital discharge. Secondary: time to first compression, rate of basic life support measures before EMS arrival, rate of patients with shockable rhythm at EMS arrival, Cerebral Performance Category at hospital discharge, and duration of hospital stay. Sample size: Assuming an absolute difference in survival rates to hospital discharge of 4% in the two groups (11% before implementation of the SAS versus 15% after) and 80% power, and a type 1 error rate of 0.05, the required sample size is N = 1,109 patients per group (at least N = 2,218 evaluated patients in total). Conclusions: The HEROES trial will investigate the effects of a SAS on the survival rate after OHCA. Trial registration: German Clinical Trials Register (DRKS, ID: DRKS00032920)

Aim: Smartphone alerting systems (SAS) alert volunteers in close vicinity of suspected out-of-hospital cardiac arrest. Some systems use sophisticated algorithms to select those who will probably arrive first. Precise estimation of departing times and travel times may help to further improve algorithms. We developed a global positioning system (GPS) based method for automatic measurements of departing times. The aim of this pilot study was to evaluate feasibility and precision of the method. Methods: Region of Lifesavers alerting app (iOS/ Android, version 3.0, FirstAED ApS, Denmark) was used in this study. 27 experiments were performed with 9 students, who were instructed to stay in their flats during the study days. A geofence was set for each alarm in the alerting system with a radius of 10 m (8 cases), 15 m (10 cases), and 20 m (9 cases) around the GPS position at which the alarm was accepted in the app. The system logged responders as being departed when the smartphone position was registered outside the geofence. The students were instructed to manually start a stopwatch at the time of the alert and to stop the stopwatch once they had entered the street in front of their flat. Results: The median difference between automatically and manually retrieved times were −16 seconds [interquartile range IQR 50 seconds] (geofence 10 m), 30 seconds [IQR 25 seconds] (15 m), and 20 seconds [IQR 13 seconds] (20 m), respectively. The 20 m geofence was associated with the smallest interquartile range. Conclusion: Departing times of volunteer responders in SAS can be retrieved automatically using GPS and a geofence.

Background and importanceThe differentiation between patients who require urgent care and those who could receive adequate care through ambulatory services remains a challenge in managing patient volumes in emergency departments (ED). Different approaches were pursued to characterize patients that could safely divert to ambulatory care. However, this characterization remains challenging as the urgency upon presentation is assessed based on immediately available characteristics of the patients rather than on subsequent diagnoses. This work employs a core set of Ambulatory Care Sensitive Conditions (core-ACSCs) in an ED to describe conditions that do not require inpatient care if treated adequately in the ambulatory care sector. It subsequently analyzes the corresponding triage levels and admission status to determine whether core-ACSCs relevantly contribute to patient volumes in an ED.Settings and participantsSingle center cross-sectional analysis of routine data of a tertiary ED in 2019.Outcome measures and analysisThe proportion of core-ACSCs among all presentations was assessed. Triage levels were binarily classified as “urgent” and “non-urgent,” and the distribution of core-ACSCs in both categories was studied. Additionally, the patients presenting with core-ACSCs requiring inpatient care were assessed based on adjusted residuals and logistic regression. The proportion being discharged home underwent further investigation.Main resultsThis study analyzed 43,382 cases of which 10.79% (n = 4,683) fell under the definition of core-ACSC categories. 65.2% of all core-ACSCs were urgent and received inpatient care in 62.8% of the urgent cases. 34.8% of the core-ACSCs were categorized as non-urgent, 92.4% of wich were discharged home. Age, triage level and sex significantly affected the odds of requiring hospital admission after presenting with core-ACSCs. The two core-ACSCs that mainly contributed to non-urgent cases discharged home after the presentation were “back pain” and “soft tissue disorders.”DiscussionCore-ACSCs contribute relevantly to overall ED patient volume but cannot be considered the primary drivers of crowding. However, once patients presented to the ED with what was later confirmed as a core-ACSC, they required urgent care in 65.2%. This finding highlights the importance of effective ambulatory care to avoid emergency presentations. Additionally, the core-ACSC categories “back pain” and “soft tissue disorders” were often found to be non-urgent and discharged home. Although further research is required, these core-ACSCs could be considered potentially avoidable ED presentations.Clinical trial registrationThe study was registered in the German trials register (DRKS-ID: DRKS00029751) on 2022-07-22.

IntroductionThe application of extracorporeal circulation (ECC) systems is known to be associated with several implications regarding hemolysis, inflammation, and coagulation. In the last years, systems with pulsatile blood flow are increasingly used with the intention to improve hemodynamics in reperfusion. However, their implications on the aforementioned aspects remain largely unknown. To investigate the effects of pulsatility, this ex-vivo study was initiated.MethodsTest circuits (primed with human whole blood) were set up in accordance with the recommendations of international standards for in-vitro evaluation of new components and systems of ECC. Diagonal pumps were either set up with non-pulsatile (n = 5, NPG) or pulsatile (n = 5, PG) pump settings and evaluated for 6 h. All analyses were conducted with human whole blood. Blood samples were repeatedly drawn from the test circuits and analyzed regarding free hemoglobin, interleukin 8 (IL-8), platelet aggregation and acquired von Willebrand syndrome (AVWS).ResultsAfter 1 h of circulation, a significant coagulation impairment (impaired platelet function and AVWS) was observed in both groups. After 6 h of circulation, increased IL-8 concentrations were measured in both groups (NPG: 0.05 ± 0.03 pg./mL, PG: 0.03 ± 0.01 pg./mL, p = 0.48). Pulsatile pump flow resulted in significantly increased hemolysis after 6 h of circulation (NPG: 37.3 ± 12.4 mg/100 L; PG: 59.6 ± 14.5 mg/100 L; p

Abstract Background The city of Freiburg has been among the most affected regions by the COVID-19 pandemic in Germany. In out of hospital cardiac arrest (OHCA) care, all parts of the rescue system were exposed to profound infrastructural changes. We aimed to provide a comprehensive overview of these changes in the resuscitation landscape in the Freiburg region. Methods Utstein-style quantitative data on OHCA with CPR initiated, occurring in the first pandemic wave between February 27th, 2020 and April 30th, 2020 were compared to the same time periods between 2016 and 2019. Additionally, qualitative changes in the entire rescue system were analyzed and described. Results Incidence of OHCA with attempted CPR did not significantly increase during the pandemic period (11.1/100.000 inhabitants/63 days vs 10.4/100.000 inhabitants/63 days, p = 1.000). In witnessed cases, bystander-CPR decreased significantly from 57.7% (30/52) to 25% (4/16) (p = 0.043). A severe pre-existing condition (PEC) was documented more often, 66.7% (16/24) vs 38.2% (39/102) there were longer emergency medical services (EMS) response times, more resuscitation attempts terminated on scene, 62.5% (15/24) vs. 34.3% (35/102) and less patients transported to hospital (p = 0.019). Public basic life support courses, an app-based first-responder alarm system, Kids Save Lives activities and a prehospital extracorporeal CPR (eCPR) service were paused during the peak of the pandemic. Conclusion In our region, bystander CPR in witnessed OHCA cases as well as the number of patients transported to hospital significantly decreased during the first pandemic wave. Several important parts of the resuscitation landscape were paused. The COVID-19 pandemic impedes OHCA care, which leads to additional casualties. Countermeasures should be taken.

Abstract Background Randomized trials have shown that trans-nasal evaporative cooling initiated during CPR (i.e. intra-arrest) effectively lower core body temperature in out-of-hospital cardiac arrest patients. However, these trials may have been underpowered to detect significant differences in neurologic outcome, especially in patients with initial shockable rhythm. Methods We conducted a post hoc pooled analysis of individual data from two randomized trials including 851 patients who eventually received the allocated intervention and with available outcome (“as-treated” analysis). Primary outcome was survival with favourable neurological outcome at hospital discharge (Cerebral Performance Category [CPC] of 1–2) according to the initial rhythm (shockable vs. non-shockable). Secondary outcomes included complete neurological recovery (CPC 1) at hospital discharge. Results Among the 325 patients with initial shockable rhythms, favourable neurological outcome was observed in 54/158 (34.2%) patients in the intervention and 40/167 (24.0%) in the control group (RR 1.43 [confidence intervals, CIs 1.01–2.02]). Complete neurological recovery was observed in 40/158 (25.3%) in the intervention and 27/167 (16.2%) in the control group (RR 1.57 [CIs 1.01–2.42]). Among the 526 patients with initial non-shockable rhythms, favourable neurological outcome was in 10/259 (3.8%) in the intervention and 13/267 (4.9%) in the control group (RR 0.88 [CIs 0.52–1.29]; p = 0.67); survival and complete neurological recovery were also similar between groups. No significant benefit was observed for the intervention in the entire population. Conclusions In this pooled analysis of individual data, intra-arrest cooling was associated with a significant increase in favourable neurological outcome in out-of-hospital cardiac arrest patients with initial shockable rhythms. Future studies are needed to confirm the potential benefits of this intervention in this subgroup of patients.

Abstract Systemic inflammation is a major feature of the post-cardiac arrest syndrome. The three monocyte subpopulations are thought to play an important role in this inflammatory state because they are endowed with numerous pattern recognition receptors, such as CD14, that have been associated with ischemia–reperfusion injury. By contrast, an exaggerated antiinflammatory response has also been described following cardiac arrest, which may be mediated by downregulation of antigen presentation receptor HLA-DR. We report the composition of monocyte subpopulations and the expression of CD14 and HLA-DR following cardiac arrest. Blood specimens were collected from 32 patients at three timepoints in the first 48 h after cardiac arrest. Monocyte subset composition was determined by flow cytometry based on the expression of CD14, CD16, and HLA-DR. Monocyte subset composition and the expression of CD14 and HLA-DR were correlated with patient outcomes. The results were compared to 19 patients with coronary artery disease. Cardiac arrest patients showed a significant decline in the percentage of nonclassical monocytes. Monocyte CD14 expression was upregulated after 24 h and correlated with the time to return of spontaneous circulation. Downregulation of HLA-DR expression was observed mainly among classical monocytes and significantly correlated with the dose of norepinephrine used to treat shock. Downregulation of HLA-DR among nonclassical and intermediate monocytes was significantly associated with disease severity. Our data demonstrate the disturbance of monocyte subset composition with a significant decline in nonclassical monocytes at an early stage following cardiac arrest. Our findings suggest the simultaneous presence of hyperinflammation, as evidenced by upregulation of CD14, and monocyte deactivation, characterized by downregulation of HLA-DR. The extent of monocyte deactivation was significantly correlated with disease severity.

Abstract Background Typical lung ultrasound (LUS) findings in patients with a COVID-19 infection were reported early on. During the global SARS-CoV-2 pandemic, LUS was propagated as a useful instrument in triage and monitoring. We evaluated LUS as a rapid diagnostic triage tool for the management of patients with suspected COVID-19 in the emergency department (ED). Methods The study retrospectively enrolled patients with suspected COVID-19, who were admitted from 1st April to 25th of April 2020 to the ED of a tertiary care center in Germany. During clinical work-up, patients underwent LUS and polymerase chain reaction (PCR) testing for SARS-CoV-2. The recorded ultrasound findings were analyzed and judged regarding typical signs of viral pneumonia, blinded for clinical information of the patients. The results were compared with PCR test and chest computed tomography (CT). Results 2236 patients were treated in the ED during the study period. 203 were tested for SARS-CoV-2 using PCR, 135 (66.5%) underwent LUS and 39 (28.9%) of the patients were examined by chest CT scan. 39 (28.9%) of the 135 patients were tested positive for SARS-CoV-2 with PCR. In 52 (38.5%) COVID-19 was suspected from the finding of the LUS, resulting in a sensitivity of 76.9% and a specificity of 77.1% compared with PCR results. The negative predictive value reached 89.2%. The findings of the LUS had - compared to a positive chest CT scan for COVID-19 - a sensitivity of 70.6% and a specificity of 72.7%. Conclusions LUS is a rapid and useful triage tool in the work-up of patients with suspected COVID-19 infection during a pandemic scenario. Still, the results of the LUS depend on the physician’s experience and skills.

OBJECTIVE: The endothelial protein C-receptor (EPCR) is an endothelial transmembrane protein that binds protein C and activated protein C (APC) with equal affinity, thereby facilitating APC formation. APC has anticoagulant, antiapoptotic and antiinflammatory properties. Soluble EPCR, released by the endothelium, may bind activated neutrophils, thereby modulating cell adhesion. EPCR is therefore considered as a possible link between the anticoagulant properties of protein C and the inflammatory response of neutrophils. In the present study, we aimed to provide proof of concept for a direct binding of EPCR to the β2-integrin Mac-1 on monocytic cells under static and physiological flow conditions. MEASUREMENTS AND MAIN RESULTS: Under static conditions, human monocytes bind soluble EPCR in a concentration dependent manner, as demonstrated by flow cytometry. Binding can be inhibited by specific antibodies (anti-EPCR and anti-Mac-1). Specific binding was confirmed by a static adhesion assay, where a transfected Mac-1 expressing CHO cell line (Mac-1+ cells) bound significantly more recombinant EPCR compared to Mac-1+ cells blocked by anti-Mac-1-antibody and native CHO cells. Under physiological flow conditions, monocyte binding to the endothelium could be significantly blocked by both, anti-EPCR and anti-Mac-1 antibodies in a dynamic adhesion assay at physiological flow conditions. Pre-treatment of endothelial cells with APC (drotrecogin alfa) diminished monocyte adhesion significantly in a comparable extent to anti-EPCR. CONCLUSIONS: In the present study, we demonstrate a direct binding of Mac-1 on monocytes to the endothelial protein C receptor under static and flow conditions. This binding suggests a link between the protein C anticoagulant pathway and inflammation at the endothelium side, such as in acute vascular inflammation or septicaemia.