Patient satisfaction in emergency medicine.

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions

Pre-procedural fasting in emergency sedation

Emergency physicians frequently undertake emergency procedural sedation in non-fasted patients. At present, no UK guidelines exist for pre-procedural fasting in emergency sedation, and guidelines from the North American Association of Anesthesiologists (ASA) designed for general anaesthesia (GA) are extrapolated to emergency care. A systematic review of the literature was conducted with the aim of evaluating the evidence for risk of pulmonary aspiration during emergency procedural sedation in adults. All abstracts were read and relevant articles identified. Further literature was identified by hand-searching reference sections. Papers were objectively evaluated for relevance against pre-determined criteria. The risk of aspiration in emergency procedural sedation is low, and no evidence exists to support pre-procedural fasting. In several large case series of adult and paediatric emergency procedural sedation, non-fasted patients have not been shown to be at increased risk of pulmonary aspiration. There is only one reported case of pulmonary aspiration during emergency procedural sedation, among 4657 adult cases and 17 672 paediatric cases reviewed. Furthermore, ASA guidelines for fasting prior to GA are based on questionable evidence, and there is high-level evidence that demonstrates no link between pulmonary aspiration and non-fasted patients. There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients at the Emergency Department. However, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation

Atropine-resistant bradycardia due to hyperkalaemia

Symptomatic sinus bradycardia is routinely treated in the emergency department with atropine and pacing. Two cases are presented that illustrate the importance of considering hyperkalaemia, particularly in the presence of atropine-resistant symptomatic bradycardia. The administration of calcium in such cases acts to stabilise the myocardium and resolve the bradycardia. Blood gas analysis provides a rapid estimate of serum potassium concentrations, facilitating timely treatment

Randomised trial of a vibrating bladder stimulator -the time to pee study

This randomised, non-blinded study evaluated a vibrating bladder stimulator to facilitate collection of a urine sample from pre-continent children. The use of a bladder stimulator produced no significant time improvements in any of the analysed parameters (n = 97). We identify a population of patients who may benefit from some form of bladder stimulation

Self-inflating bag or Mapleson C breathing system for emergency pre-oxygenation?

Background: A crossover study was performed in healthy volunteers to compare the efficacy of a self-inflating bag with the Mapleson C breathing system for pre-oxygenation. Method: 20 subjects breathed 100% oxygen for 3 min using each device, with a 30 min washout period. The end tidal oxygen concentration and subjective ease of breathing were compared. Results: There was a statistically significant difference in performance between the two devices, with the Mapleson C providing higher end expiratory oxygen concentrations at 3 min. The mean (SD) end expiratory oxygen concentration was 74.2 (3.8)% for the self-inflating bag (95% Cl 72.4% to 75.9%) and 86.2 (3.7)% for the Mapleson C system (95% Cl 84.5 to 88.0);

Can patients apply the Ottawa ankle rules to themselves?

ABSTRACT Objective: To determine whether patients with an ankle injury obtained the same results as clinicians when applying the Ottawa ankle rules (a validated clinical decision rule) to themselves. Methods: Patients aged .15 years presenting to an inner city emergency department within 48 h of an ankle injury were asked to assess their own injury using the Ottawa ankle rules. The results of their self-assessment were compared with those of a treating clinician. Results: Poor interobserver agreement was found between patients and clinicians. Conclusions: Making the Ottawa ankle rule more widely available to the general public is unlikely to reduce healthcare demand. Indeed, given the apparently low specificity of the rule, demand could actually increase as a result. The Ottawa ankle rules have been extensively validated as a clinical decision rule for use by healthcare professionals in detecting possible bony injury-and therefore the need for radiography-in patients with a recent ankle injury. 2 The Ottawa ankle rules can be reliably applied by a range of healthcare professionals, including emergency nurse practitioners. 3 If they could also be reliably applied by patients to their own ankle injuries, there is the potential to reduce healthcare consultations following ankle sprain with consequent resource savings, particularly if the rules were widely publicised. The aim of this pilot study was to determine the agreement between patients and clinicians when applying the Ottawa ankle rules, and therefore whether adult patients with a recent ankle injury are potentially able to accurately apply the Ottawa ankle rules to themselves. METHODS A convenience sample of 50 patients attending a single inner city emergency department with a recent (within 48 h) ankle injury were asked if they wished to participate in the study by a researcher triaging the patient. All patients were offered analgesia. Patients who elected not to enter the study were examined by a researcher and treated according to usual practice. If the patient entered the study, informed written consent was obtained and they were then given an information sheet and pictorial questionnaire describing the Ottawa ankle rules (see online Appendix 1). Participants were asked to examine their own ankle and to enter the results on the questionnaire before formal clinical assessment. The patient was then seen by an emergency department clinician (doctor, emergency nurse practitioner or extended scope physiotherapist) who was blind to the patient's assessment of his or her own injury. The clinician made an independent assessment of the injury and arranged radiographs as appropriate. The clinician then completed a study questionnaire giving details of his/her assessment and an interpretation of any radiographs. The formal radiology report was also reviewed and, where any disagreement occurred, the radiology report was taken as the reference standard. If radiography was not performed, the emergency and radiology department records were checked to see if the patient presented in the following month with a lower limb injury. The kappa statistic was used to determine the level of agreement between the patient and clinician, with x 2 testing to compare their overall opinion. RESULTS Fifty patients (25 men, 25 women) of mean age 32 years (range 16-63) were recruited to the study. The mean duration from injury to presentation was 17 h. All 50 patients rated themselves as positive on at least one of the five Ottawa criteria, and therefore all patients concluded that they required a radiograph. On examination by the clinician, 45 of the 50 patients were positive on at least one of the Ottawa criteria and therefore required a radiograph. Of the remaining five patients, one had a ruptured Achilles tendon and one underwent radiography for other reasons. None of the other three patients who did not undergo radiography returned to the emergency department or had lower limb radiographs at the same hospital during the following month. Of the patients who underwent radiography, seven (14%) had fractures identified by both the clinician and the reporting radiologist. Three (6%) had fractures suspected by the clinician but not confirmed by the radiologist. The remaining 36 patients (72%) who had radiographs did not have a fracture. No fractures were missed by an ED clinician. Agreement between the patient and clinician in relation to each of the five Ottawa criteria is shown in tables 1 and 2. There was very little agreement between patients and clinicians on whether they could walk initially or in the emergency department, but greater agreement regarding local tenderness. Overall, 90% of clinicians and 100% of patients rated the rule as positive, demonstrating a statistically significant difference between the final opinions of the two groups (p = 0.02, x 2 test). The kappa values show

CacheZoom: How SGX Amplifies The Power of Cache Attacks

In modern computing environments, hardware resources are commonly shared, and parallel computation is widely used. Parallel tasks can cause privacy and security problems if proper isolation is not enforced. Intel proposed SGX to create a trusted execution environment within the processor. SGX relies on the hardware, and claims runtime protection even if the OS and other software components are malicious. However, SGX disregards side-channel attacks. We introduce a powerful cache side-channel attack that provides system adversaries a high resolution channel. Our attack tool named CacheZoom is able to virtually track all memory accesses of SGX enclaves with high spatial and temporal precision. As proof of concept, we demonstrate AES key recovery attacks on commonly used implementations including those that were believed to be resistant in previous scenarios. Our results show that SGX cannot protect critical data sensitive computations, and efficient AES key recovery is possible in a practical environment. In contrast to previous works which require hundreds of measurements, this is the first cache side-channel attack on a real system that can recover AES keys with a minimal number of measurements. We can successfully recover AES keys from T-Table based implementations with as few as ten measurements.Comment: Accepted at Conference on Cryptographic Hardware and Embedded Systems (CHES '17