Jan S. K. Luitse

Syncope prevalence in the ED compared to general practice and population: a strong selection process ☆

OBJECTIVE We assessed the prevalence and distribution of the different causes of transient loss of consciousness (TLOC) in the emergency department (ED) and chest pain unit (CPU) and estimated the proportion of persons with syncope in the general population who seek medical attention from either their general practitioner or the ED/CPU. METHODS A review of the charts of consecutive patients presenting with TLOC at the ED/CPU of our university hospital between 2000 and 2002 was conducted. Patients younger than 12 years or with a known epileptic disorder were excluded. Age and sex of syncopal patients were compared with those in a general practice and general population data sets. MAIN FINDINGS AND CONCLUSIONS During the study period, 0.94% of the patients visiting the ED/CPU presented with TLOC (n = 672), of which half had syncope. Only a small but probably selected group of all people with syncope visit the ED/CPU.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

The aim of this review was to assess the value of immediate total‐body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

BackgroundComputed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients.Methods/designThe REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.DiscussionThe REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group.Trial RegistrationClinicalTrials.gov: (NCT01523626).

Assessment of a new trauma workflow concept implementing a sliding CT scanner in the trauma room: the effect on workup times.

INTRODUCTION We developed a new shockroom resuscitation setting that includes a moveable, multislice computed tomography (CT) scanner capable of scanning patients during the initial trauma resuscitation phase without (multiple) patient transfers that previously were necessary. This enables us to perform a complete diagnostic trauma workup, without leaving the shockroom. In this study, we assess the effect of the new Trauma Workflow Concept on the initial diagnostic workup times in the trauma room. MATERIALS Data of 100 consecutive trauma patients were collected prospectively (2005 cohort) and compared with 100 consecutive trauma patients seen in our previous trauma resuscitation setting (2003 cohort). For all patients, time management was evaluated using video registration and complemented with electronic imaging times. Patients with and without CT scanning were compared with the effect of CT scanning on complete workup time, defined as time from admission to the trauma room to time of completion of diagnostic workup. RESULTS Patient demographics, including appliance of CT imaging were similar. Complete diagnostic workup for patients who underwent CT imaging took an average of 79 minutes (standard deviation +/- 29 minutes) in the 2005 cohort and 105 minutes (standard deviation +/- 48 minutes) in the 2003 cohort. Complete diagnostic workup without CT imaging took 56 minutes and 53 minutes for the 2005 and 2003 cohorts, respectively. There was no difference found for nonscanned patients, whereas there was a significant difference between 2005 and 2003 for scanned patients (p < 0.01). CONCLUSION Our new trauma workflow concept with a sliding CT scanner was significantly faster for completing the initial diagnostic workup, especially when CT imaging was required.

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

BACKGROUND Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. METHODS We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. FINDINGS Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. INTERPRETATION Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. FUNDING ZonMw, the Netherlands Organisation for Health Research and Development.

Comparison of an Informally Structured Triage System, the Emergency Severity Index, and the Manchester Triage System to Distinguish Patient Priority in the Emergency Department

OBJECTIVES The objective was to compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). METHODS A total of 900 patients were prospectively triaged by six trained triage nurses using the three systems. Triage ratings of 421 (48%) patients treated only by emergency department (ED) physicians were compared with a reference standard determined by an expert panel. The percentage of undertriage, the sensitivity, and the specificity for each urgency level were calculated. The relationship between urgency level, resource use, hospitalization, and length of stay (LOS) in the 900 triaged patients was determined. RESULTS The percentage of undertriage using the ESI (86 of 421; 20%) was significantly higher than in the MTS (48 of 421; 11%). When combining urgency levels 4 and 5, the percentage of undertriage was 8% for the informally structured system (ISS), 14% for the ESI, and 11% for the MTS. In all three systems, sensitivity for all urgency levels was low, but specificity for levels 1 and 2 was high (>92%). Sensitivity and specificity were significantly different between ESI and MTS only in urgency level 4. In all 900 patients triaged, urgency levels across all systems were associated with significantly increased resource use, hospitalization rate, and LOS. CONCLUSIONS All three triage systems appear to be equally valid. Although the ESI showed the highest percentage of undertriage and the ISS the lowest, it seems preferable to use a verifiable, formally structured triage system.

The role of acute cortisol and DHEAS in predicting acute and chronic PTSD symptoms

BACKGROUND Decreased activation of the hypothalamus-pituitary-adrenal (HPA) axis in response to stress is suspected to be a vulnerability factor for posttraumatic stress disorder (PTSD). Previous studies showed inconsistent findings regarding the role of cortisol in predicting PTSD. In addition, no prospective studies have examined the role of dehydroepiandrosterone (DHEA), or its sulfate form DHEAS, and the cortisol-to-DHEA(S) ratio in predicting PTSD. In this study, we tested whether acute plasma cortisol, DHEAS and the cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks and 6 months post-trauma. METHODS Blood samples of 397 adult level-1 trauma center patients, taken at the trauma resuscitation room within hours after the injury, were analyzed for cortisol and DHEAS levels. PTSD symptoms were assessed at 6 weeks and 6 months post-trauma with the Clinician Administered PTSD Scale. RESULTS Multivariate linear regression analyses showed that lower cortisol predicted PTSD symptoms at both 6 weeks and 6 months, controlling for age, gender, time of blood sampling, injury, trauma history, and admission to intensive care. Higher DHEAS and a smaller cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks, but not after controlling for the same variables, and not at 6 months. CONCLUSIONS Our study provides important new evidence on the crucial role of the HPA-axis in response to trauma by showing that acute cortisol and DHEAS levels predict PTSD symptoms in survivors of recent trauma.

Internet-Based Early Intervention to Prevent Posttraumatic Stress Disorder in Injury Patients: Randomized Controlled Trial

Background Posttraumatic stress disorder (PTSD) develops in 10-20% of injury patients. We developed a novel, self-guided Internet-based intervention (called Trauma TIPS) based on techniques from cognitive behavioral therapy (CBT) to prevent the onset of PTSD symptoms. Objective To determine whether Trauma TIPS is effective in preventing the onset of PTSD symptoms in injury patients. Methods Adult, level 1 trauma center patients were randomly assigned to receive the fully automated Trauma TIPS Internet intervention (n=151) or to receive no early intervention (n=149). Trauma TIPS consisted of psychoeducation, in vivo exposure, and stress management techniques. Both groups were free to use care as usual (nonprotocolized talks with hospital staff). PTSD symptom severity was assessed at 1, 3, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale) by blinded trained interviewers and self-report instrument (Impact of Event Scale—Revised). Secondary outcomes were acute anxiety and arousal (assessed online), self-reported depressive and anxiety symptoms (Hospital Anxiety and Depression Scale), and mental health care utilization. Intervention usage was documented. Results The mean number of intervention logins was 1.7, SD 2.5, median 1, interquartile range (IQR) 1-2. Thirty-four patients in the intervention group did not log in (22.5%), 63 (41.7%) logged in once, and 54 (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). On clinician-assessed and self-reported PTSD symptoms, both the intervention and control group showed a significant decrease over time (P<.001) without significant differences in trend. PTSD at 12 months was diagnosed in 4.7% of controls and 4.4% of intervention group patients. There were no group differences on anxiety or depressive symptoms over time. Post hoc analyses using latent growth mixture modeling showed a significant decrease in PTSD symptoms in a subgroup of patients with severe initial symptoms (n=20) (P<.001). Conclusions Our results do not support the efficacy of the Trauma TIPS Internet-based early intervention in the prevention of PTSD symptoms for an unselected population of injury patients. Moreover, uptake was relatively low since one-fifth of individuals did not log in to the intervention. Future research should therefore focus on innovative strategies to increase intervention usage, for example, adding gameplay, embedding it in a blended care context, and targeting high-risk individuals who are more likely to benefit from the intervention. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 57754429; http://www.controlled-trials.com/ISRCTN57754429 (Archived by WebCite at http://webcitation.org/6FeJtJJyD).

Trauma outcome analysis of a Jakarta University Hospital using the TRISS method: validation and limitation in comparison with the major trauma outcome study. Trauma and Injury Severity Score.

BACKGROUND In this prospective study, the TRISS methodology is used to compare trauma care at a University Hospital in Jakarta, Indonesia, with the standards reported in the Major Trauma Outcome Study (MTOS). METHODS Between February 24, 1999, and July 1, 1999, all consecutive patients with multiple and severe trauma were included in the study (n = 105). Survival analysis was completed for 97 (92%) patients. RESULTS The majority of patients were men (81%), and the average age was 28 years. Ninety-five patients (98%) sustained blunt trauma, with motor vehicle crashes being the most common (68%). The predicted mortality was 14% and the observed mortality was 29%. The Z and M statistics were 7.87 and 0.843, respectively. CONCLUSION We conclude that in developing countries both institution-bound factors and specific limitations in the TRISS methodology are responsible for the difference between predicted and observed mortality, indicating the need for a regional database.

Influence of the Manchester triage system on waiting time, treatment time, length of stay and patient satisfaction; a before and after study.

Objectives To compare waiting time, treatment time, length of stay (LOS), patient satisfaction and distribution of waiting times over levels of urgency before and after the implementation of the Manchester Triage system (MTS) at an emergency department (ED). Methods Before and after study, by means of timeline measurements and questionnaires on satisfaction in two consecutive patient series (n=1808). Questionnaires covered aspects of provision of information, opportunity given to explain problems, waiting time and sorting out the problem. After implementation of MTS, patients were triaged between 12:00 and 22:00. Subanalysis was performed on triaging and non-triaging; and between urgency levels. Results Waiting time did not decrease after implementation of the MTS, however, treatment time and LOS were significantly longer. Total LOS did not differ. After implementation, waiting time was better distributed over urgency levels. Furthermore, after implementation, patient satisfaction scored significantly lower on the provision of information and opportunity to explain their problems, however, waiting time and the feeling that their problem had been sorted out scored better. No significant differences were found between triaged and non-triaged patients. Although not significant, patients in the lower urgency levels seemed more satisfied than patients in the higher urgency levels. Conclusions Implementing MTS on its own is not sufficient to improve efficiency and quality of EDs. More complex interventions including process redesigning that targets various groups of ED patients should be evaluated in the future by using rigorous research designs for quality improvement of EDs.