Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

The Difficult Diagnosis of Ischaemic Papillary Muscle Rupture : Case report from an urban emergency department

We present a rare case of severe ischaemic papillary muscle rupture in a 67-year-old male patient who was admitted to the Emergency Department of the University Hospital Bern, Switzerland, in November 2013 with acute chest pain. On admission, the patient’s blood pressure was 60/40 mm/Hg, his pulse was 110 beats per minute and his respiratory rate was 20 breaths per minute. An electrocardiogram was normal and focused assessment with sonography in trauma was negative. Transthoracic echocardiography showed possible thickening of the mitral valve leaflet with no indications of severe mitral insufficiency or wall motion abnormalities. Triple-ruleout computed tomography angiography revealed no pulmonary emboli or aortic dissection, although coronary atherosclerosis was present. Finally, severe insufficiency of the mitral valve with rupture of the papillary muscle, likely due to ischaemia, was observed via transoesophageal echocardiography. The patient underwent a successful surgical intervention and was discharged 10 days later in stable condition

Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.

BACKGROUND Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10). METHODS Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. RESULTS Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute ( 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. CONCLUSIONS Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization

Greece in crisis: austerity, populism and the politics of blame

Within the broader debate on the Greek crisis, the theory of ‘populist democracy’ postulates that populism is fundamental to the sustenance of the Greek political system and is at the heart of Greece's endemic domestic weaknesses. This article tests this assumption empirically through the use of a sophisticated framing analysis of speeches delivered by the leaders of the five parties in the Greek parliament in the period 2009–11. The findings confirm that populism: (a) is expressed through the narratives of political actors; (b) is observed across the party system; (c) is expressed in the forms of blame-shifting and exclusivity; and (d) differs depending on position in the party system. The article contributes to the debate by testing and building on the theory of democratic populism, providing a novel way of measuring and operationalizing populism and identifying a new typology that distinguishes between mainstream and fringe populism

Designing an effective climate-policy mix: accounting for instrument synergy

We assess evidence from theoretical-modelling, empirical and experimental studies on how interactions between instruments of climate policy affect overall emissions reduction. Such interactions take the form of negative, zero or positive synergistic effects. The considered instruments comprise performance and technical standards, carbon pricing, adoption subsidies, innovation support, and information provision. Based on the findings, we formulate climate-policy packages that avoid negative and employ positive synergies, and compare their strengths and weaknesses on other criteria. We note that the international context of climate policy has been neglected in assessments of policy mixes, and argue that transparency and harmonization of national policies may be key to a politically feasible path to meet global emission targets. This suggests limiting the complexity of climate-policy packages

Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning

Automated real-time stress monitoring of police horses using wearable technology

Mounted police horses and riders are repeatedly subjected to demanding and stressful situations. Intensive selection and training of police horses is required to ensure performance, safety and welfare of the horses and their riders. At the mounted police in Brussels, Belgium, the selection of police horses is mainly based on intuition built upon previous experience which makes it a subjective decision. Although this decision mostly leads to good results, sometimes horses are purchased that turn out to be unsuited for the mounted police. Including an objective measure when evaluating the longer term suitability of candidate police horses could help the mounted police to further improve their selection procedure for police horses. This study investigated the potential of real-time stress detection as a measure to evaluate the longer term suitability of police horses. Four experimental protocols were developed in consultation with the mounted police and were performed by 17 horse-rider pairs. The horses were divided into four categories according to their experience and suitability as police horses: good beginner, bad beginner, good experienced and bad experienced. The relative stress of the horses was monitored with wearable technology during every protocol. For one protocol, the time percentage spent over 20% relative stress by the horse was found to be significantly lower for good compared to bad beginner horses (p-value = 0.0277). In conclusion this study demonstrated that real-time stress detection with wearable technology in mounted police horses provides information on the longer term suitability of police horses