Reciprocal Abstract Publication

Mundenga MM, Diango K, Mbanjumucyo G, Kabongo D, Tenner AG

Mundenga et al. Afr J Emerg Med 2018; 8(3): 123–125.

Introduction: Even though the African Federation for Emergency Medicine (AFEM) has been successfully developing emergency care in Africa for the past 9 years, a considerable amount of potential AFEM members from the African-Francophone countries are not able to access AFEM resources. In response, an AFEM Francophone Working Group has been created to coordinate all existing and new initiatives to promote emergency care in African-Francophone countries.

Challenges that led to the creation of AFEM’s Francophone Working Group: In less than 10 years, AFEM has succeeded in gathering more than 2000 people in over 25 countries across Africa. These members now have the opportunity to improve their local and regional emergency care capacity through AFEM resources, including biannual AFEM conferences, AFEM’s educational materials, and AFEM leadership. Unfortunately, when compared to the African-English-speaking countries, French-speaking countries have been underrepresented in the past three biannual AFEM conferences held in Ghana (2012), Ethiopia (2014), and Egypt (2016). They have been unable to make use of AFEM’s educational resources due to the language barrier as almost all of AFEM’s educational materials are in English, and AFEM representation in French-speaking countries is almost non-existent. Furthermore, none of the nine African emergency medicine societies have a French training program.

The role of AFEM’s Francophone Working Group: The AFEM’s Francophone Working Group’s main goal is to help accomplish AFEM’s priorities; that is, to increase membership and awareness, to increase presence in Francophone and North African countries, to increase advocacy activities, to develop AFEM regional groups and in-country presence, and to promote acute care research and the development of African clinician researchers. Having an AFEM-Francophone section is crucial to increasing AFEM’s Francophone membership, coordinating all Francophone initiatives, helping with the AFEM material translation to French, and ensuring that standards of training in emergency care and research in emergency medicine are provided according to AFEM’s goals and vision.

Romolo J Gaspari, Alexandra Sanseverino, Timothy Gleeson

Study objective: We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone.

Methods: We performed a prospective randomized clinical trial of patients presenting with a soft-tissue abscess at a large, academic emergency department. Patients presenting with an uncomplicated soft-tissue abscess requiring incision and drainage were eligible for enrollment and randomized to treatment with or without point-of-care ultrasonography. The diagnosis of an abscess was by physical examination, bedside ultrasonography, or both. Patients randomized to the point-of-care ultrasonography group had an incision and drainage performed with bedside ultrasonographic imaging of the abscess. Patients randomized to the non–point-of-care ultrasonography group had an incision and drainage performed with physical examination alone. Comparison between groups was by comparing means with 95% confidence intervals. The primary outcome was failure of therapy at 10 days, defined as a repeated incision and drainage, following a per-protocol analysis. Multivariate analysis was performed to control for study variables. Our study was designed to detect a clinically important difference between groups, which we defined as a 13% difference.

Results: A total of 125 patients were enrolled, 63 randomized to the point-of-care ultrasonography group and 62 to physical examination alone. After loss to follow-up and misallocation, 54 patients in the ultrasonography group and 53 in the physical examination alone group were analyzed. The overall failure rate for all patients enrolled in the study was 10.3%. Patients who were evaluated with ultrasonography were less likely to fail therapy and have repeated incision and drainage, with a difference between groups of 13.3% (95% confidence interval, 0.0% to 19.4%). Abscess locations were predominantly torso (21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There was no difference in baseline characteristics between groups relative to abscess size, duration of symptoms before presentation, percentage with cellulitis, and treatment with antibiotics.

Conclusion: Patients with soft-tissue abscesses who were undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure compared with those treated without point-of-care ultrasonography.

Grant Innes, Andrew McRae, Eric Grafstein, Michael Law, Joel MH Teichman, Bryce Weber, Kevin Carlson, Heidi Boyda, James Andruchow

Innes et al. Can J Emerg Med 2018; 20(5): 702–712.

Abstract

Objectives: Some centers favor early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described. Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic. We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems.

Methods: We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics, and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases. Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports. Our primary outcome was hospitalization or urological intervention from 0 to 60 days. Secondary outcomes included ED revisits, readmissions, and rescue interventions. Time-to-event analysis was conducted and Cox proportional hazards modeling was performed to adjust for covariate imbalance.

Results: We studied 3283 patients with computed tomography (CT)-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.0% of Calgary patients and 31.3% of Vancouver patients (p < 0.001). Calgary patients had higher index intervention rates (52.1% vs 7.5%) and experienced more ED revisits and hospital readmissions during follow-up. The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other.

Conclusion: An early interventional approach was associated with higher ED revisit, hospitalization, and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones may reduce system utilization and improve outcomes for patients with acute ureteral colic.

F Javier Martín-Sánchez, Javier Perdigones, Carles Ferré Losa, Ferrán Llopis, Carmen Navarro Bustos, Carmen Borraz Ordas, Pere Llorens Soriano, Gonzalo Sempere Montes, Cesáreo Fernández Alonso, Manuel Fuentes Ferrer, Antoni Juan Pastor

Objectives: To develop a multidimensional score to assess risk of death for patients of advanced age 180 days after their admission to short-stay units (SSUs).

Methods: Prospective, multicenter, observational, and analytical study of a cohort of patients aged 75 years or older who were admitted to five Spanish SSUs between 1 February and 30 April 2014. We recorded demographic and clinical data as well as geriatric assessment scores. A multilevel logistic regression model was developed to identify independent factors associated with 180-day mortality. The model was used to construct a scale for scoring risk.

Results: Data for 593 patients with a mean (standard deviation (SD)) age of 83.4 (5.9) years entered the model; 359 (60.7%) were women. A total of 92 patients (15.5%) died within 180 days of SSU admission. Factors included in the final risk score were age over 85 years (1 point), male sex (1), loss of appetite or weight loss in the 3 months before admission (1), acute confusional state (2), functional dependence for basic activities of daily living at admission (2), and pressure ulcers (2). Low risk was indicated by a score of 0–2 points, intermediate risk by 3–5 points, and high risk by 6–9 points. Mortality rates at 180 days in these three risk groups were 5%, 18%, and 54%, respectively. The area under the receiver operating characteristic curve for the model after boots trapping was 0.72 (95% CI, 0.65–0.78).

Conclusion: The SSU score could be useful for stratifying risk of death within 6 months of SSU admission of older patients, so that type of care can be tailored to risk.

Maysam Ali Abdulwahid, Andrew Booth, Janette Turner, Suzanne M Mason

Published Online First: 5 September 2018. doi: 10.1136/emermed-2017-207107.

Abstract

Background: Optimizing the efficiency and productivity of senior doctors is critical to emergency department (ED) function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes, and provide insights into improving working conditions and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour?

Methods: The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect, and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed.

Results: A total of 14 TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%–40% of the senior doctors’ time. The remaining time was mostly spent on indirect clinical care such as communication (8%–44%), documentation (10%–28%), and administrative tasks (2%–20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high.

Conclusion: The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system.