An algorithm to improve the accuracy of emergency weight estimation in obese children

Introduction: during medical emergencies in children, accurate and appropriate weight estimations may ultimately influence the outcome by facilitating the delivery of safe and effective doses of medications. Children at the extremes of habitus, especially obese children, are more at risk of an inaccurate weight estimation and therefore may be more at risk of medication errors. The objective was therefore to develop an algorithm to guide accurate emergency weight estimation in obese children. Methods: relevant medical evidence was reviewed regarding weight estimation and its role and timing in the resuscitation of obese children. This was used as the basis for a weight-estimation algorithm. Results: there was limited evidence regarding the way the weight-estimation systems should be used in obese children other than that the dual length- and habitus-based systems were the most accurate. The methods included in the algorithm were the Broselow tape, the Mercy method, parental estimates, the paediatric advanced weight prediction in the emergency room/ eXtra Length-eXtra Large (PAWPER XL) tape and the Traub-Johnson formula. The algorithm recognised several ways in which weight estimation could be tailored to the clinical scenario to estimate both ideal and total body weight. Conclusion: weight-estimation in obese children must be conducted appropriately to avoid medication errors. This algorithm provides a framework to achieve this

A one year audit of patients with venous thromboembolism presenting to a tertiary hospital in Johannesburg, South Africa

Abstract: Introduction: Given the growing burden of venous thromboembolism (VTE) worldwide and the paucity of data from the developing world, the aim of this study was to audit the characteristics, risk factors and length of hospital stay of patients with VTE presenting to a tertiary hospital emergency centre in Johannesburg, South Africa. Methods: The study was a retrospective record review of all patients who presented with VTE to a tertiary academic emergency centre in Johannesburg, South Africa from 1 April 2012 to 30 March 2013. Results: Venous thromboembolism was identified in 74 patients; 56 (75.7%) with isolated deep vein thrombosis, 13 (17.6%) with pulmonary embolism and five (6.8%) who had a concurrent deep vein thrombosis with pulmonary embolism. The median age of the patients was 40 years old (range 19–90). The female to male ratio was 2:1. HIV infection, tuberculosis and history of immobilisation were the most common risk factors. The median duration of hospital stay was 14 days (range 4–36). A therapeutic International Normalised Ratio at discharge was only reached in 36.5% of patients. Conclusion: Venous thromboembolism presentation to the emergency centre is not common, but the risks associated with the morbidity and mortality related to it makes it important despite its relative scarcity. The prevalence of HIV infection amongst patients with VTE is concerning – not only related to the frequency of the pathology but also due to HIV not being factored into the common VTE risk stratification scores

Comparison of blood pressure in the arm and ankle in patients in the emergency department

Objectives: 1. To establish whether the differences between the arm and ankle noninvasive blood pressure (NIBP) measurements of Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Mean Arterial Pressure (MAP) are clinically relevant (i.e. a difference of 10 mmHg). 2. To determine whether any patient characteristics (age, sex, race, height, weight, body mass index (BMI), arm circumference, ankle circumference, presenting complaint, and tobacco usage) influence the difference between ankle and arm NIBP measurements. Design: Prospective cross-sectional study Setting: Netcare Union Hospital Emergency Department (ED) Patients: All patients from 18 to 50 years of age presenting to the ED who were not in need of emergency medical treatment and who consented to participating in the study. Methods: Patients had their blood pressure measured whilst lying in the supine position. The blood pressure was measured on both arms and ankles with the correct size cuff according to manufacturer’s guidelines. All appropriate data was recorded. Main Results: The blood pressure measurements in the arm and ankle were compared. SBP measurement in the ankle was found to be inaccurate when compared to the arm and thus cannot be used as a substitute for arm SBP. Ankle DBP is the most accurate and deviates from the actual arm DBP within the clinically acceptable range of 10 mmHg. MAP difference is clinically acceptable on average, but the 95% CI show that the range extends beyond the clinically acceptable range. Conclusions: Ankle blood pressure should not be used as a substitute for arm blood pressure in the Emergency Department

On-scene discharge by Emergency Care Practitioners – a viable option for South Africa?

Background: In South Africa, the national public health sector provides healthcare to the majority of the population, yet many hospitals are in a state of crisis. On-scene discharge or patient non-conveyance to hospital by Emergency Care Practitioners (ECP) may serve as a means for patients to access healthcare services while alleviating the burden on the hospitals. Aim: The aim of this study was to determine the number of patients being transported by ambulance to a public sector Emergency Department (ED) who could have potentially been managed and discharged on-scene by a South African pre-hospital ECP. Methods: This was a prospective, descriptive and quantitative study of patients brought to the ED by ambulance over a 72-hour weekend period. The medical care that was provided in the ED was compared to the existing ECP scope of practice. The patients’ disposition was also used as a surrogate to determine whether transportation to hospital was required.Results: A total of 118 patients were transported to the ED by ambulance, and 85 of these patients consented to participate in the study. Overall, 62.4% of these patients were ultimately discharged from the hospital (60.4% of discharged patients being trauma-related). Most of the treatment modalities prescribed for the discharged patients were within the ECP scope of practice.Conclusion: Pre-hospital on-scene discharge by ECPs may be a mechanism to alleviate hospital overcrowding in a failing public healthcare system. However, if an ambulance service condones the concept of on-scene discharge, they need to implement monitoring strategies to assess the subsequent outcomes for those patients discharged at the scene

The cost-effectiveness of upfront point-ofcare testing in the emergency department : a secondary analysis of a randomised, controlled trial

Abstract: Background: Time-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the timesaving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints. Methods: This was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost- Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account. Results: There were 897 medical patients randomised to receive various combinations of POC tests. The most costeffective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical. Conclusions: In certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations – the most economical POC test combination being the i- STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money

Hypothermia in trauma patients arriving at an emergency department by ambulance in Johannesburg, South Africa : a prospective study

Abstract: Introduction: Normal body temperature is considered to be between 36 and 38°C. Temperatures that are too low may negatively affect physiological functions. In trauma cases, factors that promote the development of hypothermia include concomitant hypoxia, hypotension, decreased levels of consciousness, contact with cold surfaces, exposure to low ambient temperatures and the administration of cold fluids. Studies on emergency department related hypothermia in Africa are sparse. This study investigated instances of hypothermia in a sample of trauma cases arriving by ambulance to an emergency department in Johannesburg, South Africa. Methods: Core body temperatures of 140 trauma cases were measured upon arrival and 30 minutes later. Ambient temperatures outside the hospital, inside the ED and in the resuscitation areas were also recorded. Additional information was gathered describing the equipment available to the ambulance crews for temperature, control and rewarming. Results: Seventy-two (51%) of the cases were found to have core body temperatures less than 36°C upon arrival. Twenty-nine (21%) the cases were considered clinically hypothermic (core temperatures of less than <35°C). After 30 minutes, 79 (56%) of the participants had core body temperatures of less than 36°C and 39 (28%) remained lower than 35°C. Patients were not warming up in the ED as expected. Rather, some had become colder. The study also found that the ambient temperature in the triage area fluctuated and was recorded as less than the recommended 21°C in 95 (68%) of the cases. In addition, the majority of ambulances that transported these cases lacked appropriate equipment on board to properly facilitate temperature control and rewarming. Conclusion: Fifty-one percent of the trauma cases arriving by ambulance had core temperature <36°C. Many became even colder in the ED. Attention needs to be given to the early identification of hypothermia, the regulation of ambient temperatures inside the ED including the provision of appropriate heating and rewarming devices on ambulances

Blood pressure measurements in the ankle are not equivalent to blood pressure measurements in the arm

Background. Blood pressure (BP) is often measured on the ankle in the emergency department (ED), but this has never been shown to be an acceptable alternative to measurements performed on the arm.Objective. To establish whether the differences between arm and ankle non-invasive BP measurements were clinically relevant (i.e. a difference of ≥10 mmHg).Methods. This was a prospective cross-sectional study in an urban ED making use of a convenience sample of 201 patients (18 - 50 years of age) who were not in need of emergency medical treatment. BP was measured in the supine position on both arms and ankles with the correct size cuff according to the manufacturer’s guidelines. The arm and ankle BP measurements were compared.Results. There was a clinically and statistically significant difference between arm and ankle systolic BP (SBP) and mean arterial pressure (MAP) (–13 mmHg, 95% confidence interval (CI) –28 - 1 mmHg and –5 mmHg, 95% CI –13 - 4 mmHg, respectively), with less difference in diastolic BP (DBP) (2 mmHg, 95% CI –7 - 10 mmHg). Only 37% of SBP measurements and 83% of MAP measurements were within an error range of 10 mmHg, while 95% of DBP measurements agreed within 10 mmHg. While the average differences (or the bias) were generally not large, large variations in individual patients (indicating poor precision) made the prediction of arm BP from ankle measurements unreliable.Conclusion. Ankle BP cannot be used as a substitute for arm BP in the ED

Doctors’ perceptions of the impact of upfront point-of-care testing in the emergency department

Abstract: Objectives Special investigations (e.g. blood tests, electrocardiograms, x-rays) play an integral role in patient management in the emergency department (ED). Having results immediately available prior to assessing a patient may lead to improved efficiency. This could be instituted by utilizing point-of-care (POC) testing with an alternative ED workflow, but the implementation would be dependent on acceptance by the end-users. The aim of this study was to assess doctors’ perceptions of POC testing in the ED when the normal treatment pathway was modified to use upfront POC tests performed prior to doctor evaluation in an effort to decrease treatment times. Methods A prospective, randomized, controlled trial was performed in the ED where medical patients received either the normal ED workflow pathway or one of the enhanced workflow pathways with POC tests in various combinations prior to doctor evaluation. At the end of the study period, doctors were invited to participate in an anonymous survey to gauge their opinions on the implementation of the early POC testing. Results Overall, the doctors surveyed were very satisfied with use of upfront POC in the ED. One hundred per cent of the 28 doctors surveyed found it helpful to assess patients who already had test results available and would want it to be permanently available. Normalized satisfaction scores were more favorable for combinations of 3 or more tests (0.7–1.0) as opposed to combinations with 2 or less tests (0.3–0.7). There was a preference for combinations that included comprehensive blood results. Conclusion The implementation of workflow changes to assist doctors in the ED can potentially make them more productive. End-user buy-in is essential in order for the change to be successful..