M. Simons

Validation of the Emergency Severity Index (ESI) in self-referred patients in a European emergency department

Objective: To validate the Emergency Severity Index (ESI) triage algorithm in predicting resource consumption and disposition by self-referred patients in a European emergency department. Methods: This was a prospective, observational cohort study using a convenience sample of self-referred emergency department patients >14 years of age presenting to a busy urban teaching hospital during a 39-day period (27 May–4 July 2001). Observed resource use was compared with resource utilisation predicted by the ESI. Outpatient referrals after discharge and hospitalisations were also recorded. Results: ESI levels were obtained in 1832/3703 (50%) self-referred patients, most of whom were in the less severe ESI-4 (n = 685, 37%) and ESI-5 (n = 983, 54%) categories. Use of resources was strongly associated with the triage level, rising from 15% in ESI-5 to 97% in ESI-2 patients. Specialty consultations and admissions also rose with increasing ESI severity. Only 5% of ESI-5 patients required consultation and <1% were admitted, whereas 85% of ESI-2 patients received a consultation and 56% were admitted, 26% to a critical care bed. Only 2% of the ESI-5 patients underwent blood tests, compared with 76% of the sicker ESI-2 patients. x Rays were the most commonly used resource in patients triaged to ESI-4 and ESI-5. Conclusion: The ESI triage category reliably predicts the severity of a patient’s condition, as reflected by resource utilisation, consultations and admissions in a population of self-referred patients in a European emergency department. It clearly identifies patients who require minimal resources, or at most an x ray, and those unlikely to require admission.

A description of emergency department-related malpractice claims in The Netherlands: closed claims study 1993-2001.

Background: The aim of this study was to assess the quality of care provided at emergency departments (ED) in the Netherlands by analysing medical liability insurance claims. Methods: A retrospective study performed by reviewing records at MediRisk, presently the largest insurer for medical liability in the Netherlands. The following data were abstracted from the files available for analysis: medical discipline involved, physician involved (resident or consultant), nature and gravity of the complaint, and final claim disposition. Results: Between 1993 and 2001 a total of 326 claims involving the ED were filed at MediRisk. Of these, 256 claims (79%) were closed and were available for analysis. Medical liability claims were filed primarily for alleged errors in diagnosis and treatment. The majority of claims involved minor surgical conditions: fractures, luxations (joint dislocations), wounds and tendon injuries (210/256, 82%). Residents were involved in 76% of the claims; resident supervision by a consultant was documented in only 15% of the medical records. Permanent patient disability resulting from improper ED treatment was alleged in 22% of the claims. Four per cent of the claims involved the death of a patient. Physicians accepted liability in 16% of the claims filed. Indemnity payments during the 8-year study period totalled &U20AC;504 000. Conclusion: The number of medical liability claims is low compared with the number of patients treated in ED in the Netherlands. Claims primarily concerned alleged mistakes in diagnosis and the treatment of minor trauma. Residents were involved in the majority of the claims. More resident supervision is needed, as are specific training programmes for emergency physicians.

Safety and efficacy of procedural sedation with propofol in a country with a young emergency medicine training program.

Objectives To evaluate the safety and effectiveness of procedural sedation with propofol by newly trained Dutch emergency physicians. Methods A prospective observational cohort study of patients in emergency department undergoing procedural sedation at two teaching hospitals. Primary outcomes were serious adverse events, sedation events, and efficacy. A standardized protocol and data collection form was used at both sites. Results Three hundred and eighty-six patients were enrolled over 18 months. The median age was 57 years (range 6–94, interquartile range 38–70), 55% were male patients. All had an American Society of Anesthesiologists class score of 3 or less. Indications for procedural sedation were reduction of dislocations (51%), electrocardioversion (32%), fracture reduction (8%), and abscess/wound treatment (6%). The median propofol dose was 1.0 mg/kg (0.70–1.5) and 45% received fentanyl in addition; median dose was 1 mcg/kg (0.6–1.3). Most had a Ramsay sedation score of 4 or 5. The procedural success rate was 99.5%. No serious adverse events were reported. Sedation events included; hypoventilation (11%), desaturation (5%), hypotension (3%), and bradycardia (1%), all of which resolved with simple supportive interventions. One patient vomited without aspirating. Increased age (>60 years) (P=0.001) and high Ramsay score (>3) (P=0.024) were the only significant predictors of events. Sex, weight, total dose of propofol, use of fentanyl, and type of procedure were not independent risk factors for any event. Conclusion Newly trained Dutch emergency physicians can perform procedural sedation with propofol safely and effectively. Increased age and high Ramsay scores were the only risk factors for sedation events. All events were minor and responded to simple interventions.

Single Fascia Iliaca Compartment Block is Safe and Effective for Emergency Pain Relief in Hip-fracture Patients.

Introduction Currently, it is common practice in the emergency department (ED) for pain relief in hip-fracture patients to administer pain medication, commonly systemic opioids. However, with these pain medications come a high risk of side effects, especially in elderly patients. This study investigated the safety profile and success rate of fascia iliaca compartment block (FICB) in a busy ED. This ED was staffed with emergency physicians (EPs) and residents of varying levels of experience. This study followed patients’ pain levels at various hourly intervals up to eight hours post procedure. Methods Between September 2012 and July 2013, we performed a prospective pilot study on hip-fracture patients who were admitted to the ED of a teaching hospital in the Netherlands. These patients were followed and evaluated post FICB for pain relief. Secondary outcome was the use of opioids as rescue medication. Results Of the 43 patients in this study, patients overall experienced less pain after the FICB (p=0.04). This reduction in pain was studied in conjunction with the use and non-use of opioids. A clinically meaningful decrease in pain was achieved after 30 minutes in 62% of patients (54% with the use of opioids, 8% without opioids); after 240 minutes in 82% of patients (18% with opioids, 64% without opioids); after 480 minutes in 88% of patients (16% with opioids, 72% without opioids). No adverse events were reported. Conclusion In a busy Dutch ED with rotating residents of varying levels of experience, FICB seems to be an efficient, safe and practical method for pain reduction in patients with a hip fracture. Even without the use of opioids, pain reduction was achieved in 64% of patients after four hours and in 72% of patients after eight hours.

Efficacy and safety of procedural sedation with propofol in a country with a young emergency medicine training program

Results 386 patients were enrolled over 18 months. The median age was 57 (IQR 38-70) years, 55% were male. All had ASA class score ≤ 3. Indications for procedural sedation were reduction of dislocations (52%), electro-cardioversion (32%), fracture reduction (9%) and abscess/wound treatment (6%). The median propofol dose was 1.0 mg/kg (0.70-1.5) and 44% also received fentanyl; median dose 1 mcg/kg (0.6-1.3). Most had a Ramsay sedation score of 4 or 5 (54%). The procedural success rate was 99.5%. No serious adverse events were reported. Sedation events included; hypoventilation (11%), desaturation (5%), hypotension (3%) and bradycardia (1%), all of which resolved with simple supportive interventions. One patient vomited without aspirating. Increased age (p = 0.001) and high Ramsey score (> 3) (p = 0.024) were the only significant predictors of events. Gender, weight, total dose of propofol, use of fentanyl and type of procedure were not independent risk factors for any event. Conclusion Procedural sedation with propofol can be performed safely and effectively by newly trained Dutch emergency physicians. Increased age and high Ramsay scores were the only risk factor for sedation events. All events were minor and responded to simple interventions. Possibly this study can aid the introduction of procedural sedation with propofol by emergency physicians in other countries where emergency medicine is a new and upcoming specialty.

Abstract 282 Dutch emergency department patient characteristics: implications for an emergency medicine residency program

282 Dutch emergency department patient characteristics: implications for an emergency medicine residency program J. Elshove-Bolk, F. Mencl, B. van Rijswijck, E. Weiss, M. Simons and A. van Vugt