Emergency department mean physician time per patient and workload predictors ED-MPTPP

One key element for emergency department (ED) staff calculation is the mean physician time per patient (MPTPP) and its influencing factors. The aims of this study were measuring the MPTPP, identifying factors with significant influence on the MPTPP, and developing a model to predict the MPTPP. This study was a prospective trial conducted at the ED of a university hospital in Germany. The MPTPP was measured with a specifically developed app. The influence of different factors on MPTPP were first tested in univariate analysis. Then, all significant factors were used in a multivariant regression model to minimize collinearities and to develop a prediction model. In total, 202 patients treated by 32 different physicians were observed within one year. The MPTPP was 47 min (standard deviation: 34 min). Relevant factors influencing the MPTPP were treatment area, Emergency Severity Index (ESI) triage level, guiding symptom category, and physician level (all p < 0.001). This model predicted 45% of the variance in the MPTPP (p < 0.001), which corresponds to a large effect size. We developed an effective prediction model for ED MPTPP, resulting in an MPTPP of 47 min. Future studies are needed to validate our model, which could serve as a benchmark for other EDs where the MPTPP is not available

Out-of-hospital therapeutic hypothermia in cardiac arrest victims

Despite many years of research, outcome after cardiac arrest is dismal. Since 2005, the European Resuscitation Council recommends in its guidelines the use of mild therapeutic hypothermia (32-34°) for 12 to 24 hours in patients successfully resuscitated from cardiac arrest. The benefit of resuscitative mild hypothermia (induced after resuscitation) is well established, while the benefit of preservative mild to moderate hypothermia (induced during cardiac arrest) needs further investigation before recommending it for clinical routine. Animal data and limited human data suggest that early and fast cooling might be essential for the beneficial effect of resuscitative mild hypothermia. Out-of-hospital cooling has been shown to be feasible and safe by means of intravenous infusion with cold fluids or non-invasively with cooling pads. A combination of these cooling methods might further improve cooling efficacy. If out-of-hospital cooling will further improve functional outcome as compared with in-hospital cooling needs to be determined in a prospective, randomised, sufficiently powered clinical trial

Predictors for prehospital first-pass intubation success in Germany

(1) Background: Endotracheal intubation in the prehospital setting is an important skill for emergency physicians, paramedics, and other members of the EMS providing airway management. Its success determines complications and patient mortality. The aim of this study was to find predictors for first-pass intubation success in the prehospital emergency setting. (2) The study was based on a retrospective analysis of a population-based registry of prehospital advanced airway management in Germany. Cases of endotracheal intubation by the emergency medical services in the cities of Tübingen and Jena between 2016 and 2019 were included. The outcome of interest was first-pass intubation success. Univariate and multivariable regression analysis were used to analyse the influence of predefined predictors, including the characteristics of patients, the intubating staff, and the clinical situation. (3) Results: A total of 308 patients were analysed. After adjustment for multiple confounders, the direct vocal cord view, a less favourable Cormack–Lehane classification, the general practitioner as medical specialty, and location and type of EMS were independent predictors for first-pass intubation success. (4) Conclusions: In physician-led emergency medical services, the laryngoscopic view, medical specialty, type of EMS, and career level are associated with FPS. The latter points towards the importance of experience and regular training in endotracheal intubation

Prescribing in a paediatric emergency: A PERUKI survey of prescribing and resuscitation aids

Aim: The aim was to investigate the use of paper-based and electronic prescribing and resuscitation aids in paediatric emergency care from a departmental and individual physician perspective. Methods: A two-stage web-based self-report questionnaire was performed. In stage (i), a lead investigator at PERUKI sites completed a department-level survey; in stage (ii), individual physicians recorded their personal practice. Results: The site survey was completed by 46/54 (85%) of PERUKI sites. 198 physicians completed the individual physicians' survey. Individual physicians selected the use of formulary apps for checking of medication dosages nearly as often as hardcopy formularies. The APLS WETFLAG calculation and hardcopy aids were widely accepted in both surveys. A third of sites accepted and half of the individual physicians selected resuscitation apps on the personal mobile device as paediatric resuscitation aids. Conclusion: Our survey shows a high penetrance of the British National Formulary app, a success of NHS digital policy and strategy. Despite potential advantages, many physicians in our survey do not use resuscitation apps. Reluctance to engage with apps is likely to be multifactorial and includes human factors. These obstacles need to be overcome to create a digital healthcare culture

Deep vein thrombosis and pulmonary embolism: a prospective, observational study to evaluate diagnostic performance of the Tina-quant D-Dimer Gen.2 assay

BackgroundD-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic performance of the Tina-quant® D-Dimer Gen.2 assay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) in patients with low/intermediate pre-test probability of DVT/PE using standard, age-, and clinical probability-adjusted cut-offs.MethodsIn this prospective, observational, multicenter study (July 2017–August 2019), plasma samples were collected from hospital emergency departments and specialist referral centers. DVT/PE was diagnosed under hospital standard procedures and imaging protocols. A standard D-dimer cut-off of 0.5 µg fibrinogen equivalent units (FEU)/ml was combined with the three-level Wells score; cut-offs adjusted for age (age × 0.01 µg FEU/ml for patients &gt;50 years) and clinical probability (1 µg FEU/ml for low probability) were also evaluated. An assay comparison was conducted in a subset of samples using the Tina-quant D-Dimer Gen.2 assay and the previously established routine laboratory assay, STA-Liatest D-Di Plus assay (Stago Deutschland GmbH, Düsseldorf, Germany).Results2,897 patients were enrolled; 2,516 completed the study (DVT cohort: 1,741 PE cohort: 775). Clinical assessment plus D-dimer testing using the standard cut-off resulted in 317 (DVT) and 230 (PE) false positives, and zero (DVT) and one (PE) false negatives. Negative predictive value (NPV) was 100.0% (95% confidence interval [CI]: 99.7%–100.0%) and 99.8% (95% CI: 98.8%–100.0%) for DVT and PE, respectively. After age-adjustment, NPV was 99.9% (95% CI: 99.6%–100.0%) and 99.1% (95% CI: 97.8–99.7) for DVT and PE, respectively. False positive rates decreased (&gt;50%) in clinical probability-adjusted analyses vs. primary analysis. In the assay comparison, the performances of the two assays were comparable.ConclusionThe Tina-quant D-Dimer Gen.2 assay and standard D-dimer cut-off level combined with the three-level Wells score accurately identified patients with a very low probability of DVT/PE

Fgf9 and Wnt4 Act as Antagonistic Signals to Regulate Mammalian Sex Determination

The genes encoding members of the wingless-related MMTV integration site (WNT) and fibroblast growth factor (FGF) families coordinate growth, morphogenesis, and differentiation in many fields of cells during development. In the mouse, Fgf9 and Wnt4 are expressed in gonads of both sexes prior to sex determination. Loss of Fgf9 leads to XY sex reversal, whereas loss of Wnt4 results in partial testis development in XX gonads. However, the relationship between these signals and the male sex-determining gene, Sry, was unknown. We show through gain- and loss-of-function experiments that fibroblast growth factor 9 (FGF9) and WNT4 act as opposing signals to regulate sex determination. In the mouse XY gonad, Sry normally initiates a feed-forward loop between Sox9 and Fgf9, which up-regulates Fgf9 and represses Wnt4 to establish the testis pathway. Surprisingly, loss of Wnt4 in XX gonads is sufficient to up-regulate Fgf9 and Sox9 in the absence of Sry. These data suggest that the fate of the gonad is controlled by antagonism between Fgf9 and Wnt4. The role of the male sex-determining switch— Sry in the case of mammals—is to tip the balance between these underlying patterning signals. In principle, sex determination in other vertebrates may operate through any switch that introduces an imbalance between these two signaling pathways