Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality – a retrospective study from a Swiss university hospital

AIMS OF THE STUDY While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER. METHODS Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national government’s initiative “How to protect ourselves” on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16–30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group. RESULTS In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared to the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp. CONCLUSIONS Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients

Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.

OBJECTIVES Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. METHODS We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. RESULTS Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker. CONCLUSIONS The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation

Automated identification of diagnostic labelling errors in medicine

Objectives: Identification of diagnostic error is complex and mostly relies on expert ratings, a severely limited procedure. We developed a system that allows to automatically identify diagnostic labelling error from diagnoses coded according to the international classification of diseases (ICD), often available as routine health care data. Methods: The system developed (index test) was validated against rater based classifications taken from three previous studies of diagnostic labeling error (reference standard). The system compares pairs of diagnoses through calculation of their distance within the ICD taxonomy. Calculation is based on four different algorithms. To assess the concordance between index test and reference standard, we calculated the area under the receiver operating characteristics curve (AUROC) and corresponding confidence intervals. Analysis were conducted overall and separately per algorithm and type of available dataset. Results: Diagnoses of 1,127 cases were analyzed. Raters previously classified 24.58% of cases as diagnostic labelling errors (ranging from 12.3 to 87.2% in the three datasets). AUROC ranged between 0.821 and 0.837 overall, depending on the algorithm used to calculate the index test (95% CIs ranging from 0.8 to 0.86). Analyzed per type of dataset separately, the highest AUROC was 0.924 (95% CI 0.887-0.962). Conclusions: The trigger system to automatically identify diagnostic labeling error from routine health care data performs excellent, and is unaffected by the reference standards' limitations. It is however only applicable to cases with pairs of diagnoses, of which one must be more accurate or otherwise superior than the other, reflecting a prevalent definition of a diagnostic labeling error

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways

Development, implementation and first insights of a time- and location-independent longitudinal postgraduate curriculum in emergency medicine.

There have been few reports on the implementation of a structured curriculum for emergency medicine, as emergency medicine is not yet an established medical specialty for training in many European countries, including Switzerland and Germany. Because of the non-plannable workload in the emergency setting, common training approaches are often difficult to implement. Need-assessments of emergency medicine trainees commonly identify a need for interactive, time-independent ways of learning that integrate modern forms of knowledge transfer. In the present study, we assess the local needs of emergency medicine specialists and trainees for a curriculum in emergency medicine and elaborate possible solutions for the implementation of this curriculum, taking into account the special needs in a highly dynamic, unplannable environment, such as an interdisciplinary emergency department. We describe the development of the emergency medicine curriculum on the basis of the six steps proposed by Kern for curriculum development in medical education, as well as the implementation, lessons learned and interval evaluation. The combination of multiple teaching formats, ranging from time- and location-independent solutions such as podcasted lectures to simulation-based training sessions, as well as small-group workshops and skill training sessions, might be a valuable approach to implementing a state-of-the-art curriculum in a busy emergency department

Severity and pattern of injuries caused by Swiss wrestling (Schwingen): first retrospective study at a level I University Emergency Department in Switzerland

Background: This article addresses typical injury patterns related to the traditional Swiss folk wrestling, 'Schwingen'. This is a fight between two competitors with its own rules, grips and throws. A variety of injuries have been occasionally reported. The aim of this study was to characterise all cases of Schwingen injuries treated in the University Hospital of Bern from January 2006 to July 2016. Methods: To assess the frequency, type and outcome of Schwingen injuries, database search was performed of all inpatient and outpatient cases related to Schwingen that were admitted to Bern University Hospital from January 2006 to December 2016. Results: A total of 32 such patients could be identified. Apart from a single woman, all patients were male. 31 of the 32 players were Swiss. One patient was admitted to the intermediate care unit, eight patients underwent surgery, two were hospitalised for further treatment and two were given a plaster. 17 other patients were given medications such as painkillers. One was dismissed without further treatment and another one left the hospital on his own. Typical injury patterns varied from simple lesions to distortions and fractures as well as head injuries and other neurological complications. Conclusion: The majority of injuries caused by Schwingen are not life threatening. Nevertheless, there is always the potential of head injuries and neurological deficits. Apart from the economic loss due to treatment costs and sick leave, these injuries can be disabling for life. It should therefore be obligatory for all players to evaluate preventive measures

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways

Increased Urgent Care Center Visits by Southeast European Migrants: A Retrospective, Controlled Trial from Switzerland

We investigated whether immigrants from Southeast Europe (SE) and Swiss patients have different reasons for visiting the emergency department (ED). Our retrospective data analysis for the years 2013–2017 describes the pattern of ED consultations for immigrants from SE living in Switzerland (Canton Bern), in comparison with Swiss nationals, with a focus on type of referral and reason for admission. A total of 153,320 Swiss citizens and 12,852 immigrants from SE were included in the study. The mean age was 51.30 (SD = 21.13) years for the Swiss patients and 39.70 (SD = 15.87) years for the SE patients. For some countries of origin (Albania, Bosnia and Herzegovina, and Turkey), there were highly statistically significant differences in sex distribution, with a predominance of males. SE immigrants had a greater proportion of patients in the lower triage level (level 3: SE: 67.3% vs. Swiss: 56.0%) and a greater proportion of patients in the high triage level than the Swiss population (level 1: SE: 3.4% vs. Swiss: 8.8%). SE patients of working age (16–65 years) were six times more often admitted by ambulance than older (≥65 years) SE patients, whereas this ratio was similar in the Swiss population. In both groups, the fast track service was primarily used for patients of working age (<65) and more than three times more often in the SE than the Swiss group (SE: 39.1%, Swiss: 12.6%). We identified some indications for access to primary care in emergency departments for immigrants and highlighted the need for attention to the role of organizational characteristics of primary health care in Switzerland. We highlighted the need for professional support to improve the quality of healthcare for immigrants. In the future, we will need more primary care services and general practitioners with a migrant background

Predictors of High Resource Consumption in Alcohol Intoxicated Patients in the Emergency Department

Background: previous studies have reported that the incidence of alcohol-related visits to emergency departments (ED) has increased, but little is known about how the necessary resources per visit have changed, or about the predictors and reasons for resource consumption. Methods: a retrospective analysis was performed of all consultations with a primary or secondary diagnosis of acute alcohol intoxication admitted to the ED of Bern University Hospital, Switzerland, between 1 June 2012, and 31 May 2017. Clinical characteristics and resource consumption were extracted and analysed over time. Results: in all, 196,045 ED consultations included 2586 acute alcohol intoxications, corresponding to 1.3% of the total. The incidences of acute alcohol intoxications have tended to increase over the last five years, and a growing number of visits have consumed high resources (consultations above the 75th percentile for total resource consumption). High resource consumption was associated with greater age and the male gender (p < 0.001). The main predictors of resource consumption were fractures (Odds ratio (OR): 3.9, 95% CI 2.8-5.3, p < 0.001), dislocations (OR 3.7, 95%: 1.5-9.1, p < 0.001), and traumatic brain injury (3.5, 2.5-5.1, p < 0.001). Consultations consuming high resources mostly required radiology resources (45%); consultations consuming low or normal resources mostly required physicians' work (45%) or nurses' work (27%). Conclusions: the number of alcohol intoxications consuming high resources has increased over the last five years. Acute alcohol intoxication associated with trauma is resource intensive, especially with regard to radiology resources. This underlines the need for further efforts to prevent alcohol-related traffic accidents, for examples