The need of a health technology assessment perspective in emergency medicine

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Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis

: Trauma is one of the leading causes of uncontrolled haemorrhage, death, and disability. Use of a tourniquet can be considered an optimal anti-haemorrhagic resource, in pre-hospital and emergency settings, and its lifesaving effect is clinically contradictory. This review aims to assess the clinical efficacy of the tourniquet in the emergency pre-hospital care setting for the management of haemorrhage. We conducted the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the PRISMA statement. We searched the following electronic databases: EMBASE, MEDLINE, and Cochrane-CENTRAL. All studies included were appraised for risk of bias. Prevalent primary outcomes were mortality and use of blood products. Secondary outcomes were related to adverse effects. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Four studies were involved (1762 trauma patients). The adjusted odds ratio (aOR) of 0.47 (95% confidence Interval (CI) 0.19-1.16; three studies; 377 patients) for overall mortality estimates did not give a clear indication of the benefits of emergency pre-hospital tourniquets (PH-TQ) versus no pre-hospital tourniquet (NO PH-TQ) placement. The adjusted mean difference for blood product use was -3.28 (95% CI -11.22, 4.66) for packed red blood cells (pRBC) and -4.80 (95% CI -5.61, -3.99) for plasma, respectively. The certainty of evidence was downgraded to very low for all outcomes. Our results suggest an unclear effect of emergency pre-hospital tourniquet placement on overall mortality and blood product use. However, this systematic review highlights the availability of only observational studies and the absence of high quality RCTs assessing the efficacy of PH-TQs. Randomized controlled trials are needed

Italian Consensus Statement on Patient Engagement in Chronic Care: Process and Outcomes

Patient engagement has been recognized as a key priority in chronic care. However,scholars agree that guidelines are needed to ensure effective patient engagement strategies. Tothis end, a Consensus Conference process was promoted with the following methodological steps:(1) extensive literature review about patient engagement initiatives in chronic care; (2) a stakeholderssurvey to collect best practices and (3) workshops with experts. On the basis of the informationcollected, a consensus statement was drafted, revised, and finalized by a panel of select renownedexperts. These experts agreed in defining engagement as an eco-systemic concept involving multipleactors all of which contribute to influence patients\u2019 willingness and ability to engage in chronic care.Moreover, experts recommended, whenever possible, to adopt standardized instruments to assess engagement levels and related unmet needs. Then, experts strongly advised appropriate trainings for healthcare professionals about patient engagement strategies. Furthermore, the importance of promoting healthcare professionals\u2019 wellbeing has been advocated. Family caregivers, as well as patients\u2019 organizations - should be trained and engaged to increase the effectiveness of interventions dedicated to patients. Finally, experts agreed that digital technologies should be considered as acrucial enhancer for patient engagement in chronic car

A research agenda for Italian emergency medicine

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Ameliorating the emergency department workflow by involving the observation unit: effects on crowding

Crowding adversely affects the performance of emergency departments (EDs) by worsening efficiency, timeliness of care, clinical outcomes and patients’ satisfaction. We describe in this study our attempt at improving crowding by modifying the roles and workflow of the ED physicians. The observation unit physician was given the additional duty of prioritizing admissions and managing unclear, complex cases, which were previously under the responsibility of front line emergency physicians. We analyzed two corresponding periods, both before the intervention (9897 ED attendances) in 2012 and after the intervention (10,297 attendances) in 2013. Most of the crowding indices improved significantly, including timeliness of triage, of first medical contact, access to resus area, and overall length of stay in ED. Also, emergency hospital admissions, average specialist consultations and imaging studies per patient decreased significantly. The observation unit workload increased. There was no significant excess of adverse events

Palpitations

In the vast majority of cases, palpitations are a symptom of little clinical importance that does not warrant any particular diagnostic investigations other than a careful medical history, physical examination and standard 12-lead ECG. However, it should not be underestimated as it can be the only important symptom preceding a sudden death (sometimes in young subjects). It is not always possible to evaluate these cases swiftly. However, it requires all the physician’s skill to weigh up the medical history, clinical and electrocardiographic elements that constitute warning signs. We have observed that a history of palpitations or valve disease, fainting, especially due to exertion and poorly tolerated paroxysmal palpitations are all alarm elements. In the early weeks of life, we observed that certain subgroup of patients is at very high risk of sudden death and is unfortunately not diagnosed properly for slight and relatively unknown ECG alterations (Brugada syndrome, ARVD, long QT syndrome, idiopathic ventricular tachycardia) and the underestimation of warning signs (palpitations caused by exertion, unexplained episodes of fainting). The aim of this short work is to provide elements for guiding the identification of this very generic, misleading and complex symptom

Acute abdominal pain: emergency diagnosis and treatment (Part II)

Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home

Acute abdominal pain: emergency diagnosis and managing (Part I)

Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home

A systematic review on the validity and reliability of an emergency department triage scale, the Manchester Triage System

Objective: To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic. Design: This is a systematic review based on the PRISMA guideline on reporting systematic reviews. Data sources: The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases. Review methods: This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department.After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines. Results: Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the "kappa" statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating. Conclusions: In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good