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PubMed1999

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.

Attitude of Health Personnel↗

PubMed2004

Requests for emergency contraception at an accident and emergency department--assessing the impact of a change in legislation.

The aim of this study was to examine the pattern of attendance of patients requesting Emergency Hormonal Contraception (EHC) at an accident and emergency department before and after a government driven change in legislation, which allowed EHC to be sold over-the-counter by trained pharmacists, to women aged 16 years and above. We employed retrospective comparative study using computer records of all accident and emergency attendances coded as requests for emergency contraception for the years 2000 and 2001. The number of patients requesting emergency contraception at the A&E department decreased after over-the-counter sales were introduced, from 196 in the year 2000 to 164 in 2001 (p = 0.037). Despite this, the number of teenagers requesting emergency contraception at the A&E department increased in 2001--from 63 in 2000 to 74 in 2001 (p = 0.0115). Most requests are received outside local pharmacy opening hours--63.77% in 2000 and 62.2% in 2001. This study raises concerns that the government initiative allowing emergency hormonal contraception to be sold in pharmacies is having little impact on teenagers most in need of this service. A&E departments can expect to continue to receive a significant number of requests for emergency contraception. Further measures will be required to reduce the U.K.'s high rate of unplanned pregnancies.

Adolescent↗

PubMed1988

Coronary bypass grafting after failed elective and failed emergent percutaneous angioplasty. Relative risks of emergent surgical intervention.

Emergency coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty can be performed with acceptable complication rates. Recently, however, a new class of patients with unsuccessful angioplasty has evolved with the use of thrombolytic therapy and emergent angioplasty as treatment for developing acute myocardial infarction. The efficacy of surgical intervention after failure of angioplasty in this setting has not been demonstrated. This report compares the results of coronary bypass done emergently after either failed elective or failed emergent angioplasty. Between March 1984 and September 1986; 1350 angioplasty procedures were performed at our institution, 393 for acute myocardial infarction. Of the 111 patients who came to operation, 42 had had unsuccessful elective angioplasty and 69 unsuccessful angioplasty done in the clinical setting of an evolving acute myocardial infarction detected by electrocardiographic criteria. Twenty-one of the 42 patients having unsuccessful elective angioplasty (group I) and 32 of the 69 with unsuccessful emergent angioplasty (group II) underwent emergency coronary artery bypass grafting. A retrospective nonparametric statistical comparison of the two groups was performed. Age, preoperative ejection fraction, distribution of vessels undergoing angioplasty, and number of vessels bypassed were not statistically different. All group II patients received thrombolytic therapy, and a reperfusion catheter was used in over half the patients in each group. Three group I and six group II patients required a preoperative balloon pump, and half the patients in each group required postoperative inotropic support. One patient in group I (4.7%) and two patients in group II (6.2%) died (no significant difference). Only five patients in group I (23.8%) and 11 in group II (34.3%) had enzymatic and electrocardiographic evidence of an acute myocardial infarction at discharge. Six patients in group II (15.6%) required reexploration for bleeding, versus none in group I (p = 0.04). Nonhemorrhagic complication rates, mean in-patient and acute care days, total hospital charges, and blood product utilization rates were not statistically different. These data indicate that emergency coronary artery bypass grafting can be performed when necessary in the setting of failed emergent percutaneous transluminal coronary angioplasty with results comparable to coronary bypass after failed elective angioplasty.

Angioplasty, Balloon↗

PubMed1996

Guidelines for the emergency management of asthma in adults. CAEP/CTS Asthma Advisory Committee. Canadian Association of Emergency Physicians and the Canadian Thoracic Society.

OBJECTIVE: To develop a set of comprehensive, standardized evidence-based guidelines for the assessment and treatment of acute asthma in adults in the emergency setting. OPTIONS: The use of medications was evaluated by class, dose, route, onset of action and optimal mode of delivery. The use of objective measurements and clinical features to assess response to therapy were evaluated in relation to the decision to admit or discharge the patient or arrange for follow-up care. OUTCOMES: Control of symptoms and disease reflected in hospital admission rates, frequency of treatment failures following discharge, resolution of symptoms and improvement of spirometric test results. EVIDENCE: Previous guidelines, articles retrieved through a search of MEDLINE, emergency medical abstracts and information from members of the expert panel were reviewed by members of the Canadian Association of Emergency Physicians (CAEP) and the Canadian Thoracic Society. Where evidence was not available, consensus was reached by the expert panel. The resulting guidelines were reviewed by members of the parent organizations. VALUES: The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examination were used. BENEFITS, HARMS AND COSTS: As many as 80% of the approximate 400 deaths from asthma each year in Canada are felt to be preventable. The use of guidelines, aggressive emergency management and consistent use of available options at discharge are expected to decrease the rates of unnecessary hospital admissions and return visits to emergency departments because of treatment failures. Substantial decreases in costs are expected from the use of less expensive drugs, or drug delivery systems, fewer hospital admissions and earlier return to full activity after discharge. RECOMMENDATIONS: Beta2-agonists are the first-line therapy for the management of acute asthma in the emergency department (grade A recommendation). Bronchodilators should be administered by the inhaled route and titrated using objective and clinical measures of airflow limitation (grade A). Metered-dose inhalers are preferred to wet nebulizers, and a chamber (spacer device) is recommended for severe asthma (grade A). Anticholinergic therapy should be added to beta 2 agonist therapy in severe and life-threatening cases and may be considered in cases of mild to moderate asthma (grade A). Aminophylline is not recommended for use in the first 4 hours of therapy (grade A). Ketamine and succinylcholine are recommended for rapid sequence intubation in life-threatening cases (grade B). Adrenaline (administered subcutaneously or intravenously), salbutamol (administered intravenously) and anesthetics (inhaled) are recommended as alternatives to conventional therapy in unresponsive life-threatening cases (grade B). Severity of airflow limitation should be determined according to the forced expiratory volume at 1 second or the peak expiratory flow rate, or both, before and after treatment and at discharge (grade A). Consideration for discharge should be based on both spirometric test results and assessment of clinical risk factors for relapse (grade A). All patients should be considered candidates for systemic corticosteroid therapy at discharge (grade A). Those requiring corticosteroid therapy should be given 30 to 60 mg of prednisone orally (or equivalent) per day for 7 to 14 days; no tapering is required (grade A). Inhaled corticosteroids are an integral component of therapy and should be prescribed for all patients receiving oral corticosteroid therapy at discharge (grade A). Patients should be given a discharge treatment plan and clear instructions for follow-up care (grade C). VALIDATION: The guidelines share the same principles of those from the British Thoracic Society and the National Institutes of Health. Two specific validation initiatives have been undertaken: (a) several Canadian centres have been involved in the collection of comprehensive administrative data to assess compliance and outcome measures and (b) a survey of Canadian emergency physicians conducted to gather baseline informaton of treatment patterns, was conducted before development of the guidelines and will be repeated to re-evaluate emergency management of asthma.

Adult↗

PubMed2006

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Cause of Death↗

PubMed2006

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Cause of Death↗

PubMed1994

Does learning emergency medicine equip medical students for ward emergencies?

The aim of this study was to assess the competence of senior medical students in recognizing and managing life-threatening ward emergencies and to compare the competence of a group that had received emergency medicine teaching with one that had not. This was achieved by asking 60 final year medical students to complete a structured written clinical examination designed to test these skills. Comparisons were made between the group that had received emergency medicine teaching (the 'taught' group) and that which had not (the 'untaught' group) with respect to numerical scores on the examination and the number of fatal management errors committed. The 'taught' group had an average total score of 285/400 compared with an average score of 223/400 for the 'untaught' group (P < 0.001). The 'untaught' group committed 0.25 fatal errors per student per case compared with the 'taught' group that committed 0.06 fatal errors per student per case (P < 0.001). There is considerable scope to improve the competence of senior medical students for dealing with life-threatening ward emergencies. Students who had received emergency medicine teaching scored significantly better than those who had not suggesting that emergency medicine teaching is a suitable tool to help equip medical students to deal with life threatening ward emergencies.

Clinical Competence↗

PubMed1999

Emerging and re-emerging infections.

An emerging infection is defined as an infection which has newly appeared in a population while a re-emerging infection is one which has existed in the past but its incidence is rapidly increasing. The reasons for the emergence and re-emergence of infections are not well understood but appear to be associated with factors that involve the pathogen, the host and the environment. These factors are often inter-related and act together in a complex manner to bring about changes in patterns of infection. Pathogens are extremely resourceful and possess mechanisms to adapt to new hosts and environments as well as to acquire new virulence traits. Host factors include herd immunity, social behaviour and demographics. Environmental factors like the climate, deforestation and new technologies have an impact on the emergence of infections. The challenge is to contain an infection when it emerges but more importantly to prevent its emergence in the first place. As the emergence of an infection is complex and multifactorial, a multidisciplinary approach is required. Health based strategies alone are insufficient. Social, economic and environmental measures and the political will to implement appropriate policies are equally important.

Environment↗

PubMed2004

[Invasive techniques in emergency medicine. I. Practice-oriented training concept to ensure adequately qualified emergency physicians].

Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.

Clinical Competence↗

PubMed2006

Emergency radiology today between philosophy of science and the reality of "emergency care".

In the past 20 years, emergency care concept has substantially changed on a cultural point of view, going well beyond the boundaries of medical science. It is now a general understanding that the real enemy of the critical patient is time; thus, functional organisation and collocation of human and technological resources in the emergency department (ED) can help avoid the loss of human lives. This "cultural revolution" led to the creation and development of structural and organisational models (layouts) of EDs. Now, emergency radiology has a central role in ED organisation, and the radiologist, providing 24-h coverage in the emergency room, is crucial for the correct diagnostic approach and rapid management of trauma. If this is the cultural background to the "emergency care" concept, an overview of such care in our country shows great differences from a structural, technological and organisational point of view. The presence of the radiologist providing 24-h coverage in the emergency room is still uncommon in many EDs The qualification of emergency care must be sought by studying the needs of the population and by seeking qualified personnel with high professional skill levels. All this must be understood and pursued by politicians and health care managers whose aim should be to coordinate and check the measures and human resources applied to the system. This process necessarily involves rewarding those health care professionals who prove to be up to the job.

Clinical Competence↗

PubMed1986

Community hospital management of pediatric emergencies: implications for pediatric emergency medical services.

The ability of emergency physicians in a general community hospital to manage pediatric patients was evaluated. Essential diagnostic and therapeutic procedures performed in the emergency department on pediatric patients transferred for admission to a tertiary care center were compared with those initially performed on the same patients by the pediatricians and residents of the tertiary care center. The overall care rendered by the emergency physicians correlated well with that of the referral center. Ninety one per cent of diagnostic studies and 96% of therapeutic interventions were performed in the emergency department. Implications for the care of seriously ill pediatric patients by emergency physicians and the role of community hospital emergency departments in pediatric emergency medical services (EMS) systems are discussed.

Adolescent↗

PubMed2006

Emergency medicine and the health of the public: the critical role of emergency departments in US public health.

This issue of the Emergency Medicine Clinics of North America focuses on the spectrum of public health issues that significantly impact the practice of emergency medicine and which are faced by practicing emergency physicians on daily basis. Topics include public health research in the emergency department; respiratory threats; emerging infectious diseases; emergency department overcrowding; end-of-life care; racial and ethnic disparities; issues of health promotion and disease prevention encompassing substance abuse, alcohol, and injury and violence; and public health surveillance; and the problems of homeless and disadvantaged patients. This article gives a brief introduction to the important relationship between emergency medicine and public health.

Emergency Medicine↗

PubMed2000

A preliminary evaluation of emergency ultrasound in the setting of an emergency medicine training program.

In this article we seek to evaluate the diagnostic accuracy of emergency physicians performing emergency ultrasonography in the setting of an emergency medicine training program. A prospective observational study was performed at an inner city Level I trauma center with an emergency medicine residency training program. From July 1994 to December 1996 a convenience sample of ultrasound exams was recorded. The diagnostic quality ("acceptable or technically limited") was determined by a board-certified cardiologist or radiologist with fellowship training in ultrasonography. The emergency department interpretations were then compared to those of the blinded cardiologist or radiologist. Four hundred and fifty-six ultrasound examinations were videotaped and entered into the study; 408 (89%) of the studies performed were determined to be "acceptable." The diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of these studies were as follows: cardiac, to rule out effusion (n = 67; 0.83, 0.98, 0.88, 0.98); transabdominal, to rule out abdominal aortic aneurysms (AAA), cholelithiasis, or free peritoneal fluid (n = 263; 0.91, 0.89, 0.88, 0.92); renal, to rule out hydronephrosis (n = 45; 0.94, 0.96, 0.94, 0.96); pelvic, to rule in intrauterine pregnancy (n = 33; 1.0, 0.90, 0.96, 1.0). The 48 "technically limited studies" included: 39 transabdominal (33 gallbladder, 1 abdominal aortic aneurysm, 5 free peritoneal fluid), 6 cardiac, 2 renal, and 1 pelvic ultrasound. This study suggests that emergency physicians with a minimal amount of training display acceptable technical skill and interpretive acumen in their approach to emergency ultrasonography.

Clinical Competence↗

PubMed1991

Unsuccessful emergency medical resuscitation--are continued efforts in the emergency department justified?

BACKGROUND: The majority of attempts to resuscitate victims of prehospital cardiopulmonary arrest are unsuccessful, and patients are frequently transported to the emergency department for further resuscitation efforts. We evaluated the efficacy and costs of continued hospital resuscitation for patients in whom resuscitation efforts outside the hospital have failed. METHODS: We reviewed the records of 185 patients presenting to our emergency department after an initially unsuccessful, but ongoing, resuscitation for a prehospital arrest (cardiac, respiratory, or both) by an emergency medical team. Prehospital and hospital characteristics of treatment for the arrest were identified, and the patients' outcomes in the emergency room were ascertained. The hospital course and the hospital costs for the patients who were revived were determined. RESULTS: Over a 19-month period, only 16 of the 185 patients (9 percent) were successfully resuscitated in the emergency department and admitted to the hospital. A shorter duration of prehospital resuscitation was the only characteristic of the resuscitation associated with an improved outcome in the emergency department. No patient survived until hospital discharge, and all but one were comatose throughout hospitalization. The mean stay in the hospital was 12.6 days (range, 1 to 132), with an average of 2.3 days (range, 1 to 11) in an intensive care unit. The total hospital cost for the 16 patients admitted was $180,908 (range per patient, $1,984 to $95,144). CONCLUSIONS: In general, continued resuscitation efforts in the emergency department for victims of cardiopulmonary arrest in whom prehospital resuscitation has failed are not worthwhile, and they consume precious institutional and economic resources without gain.

Cardiopulmonary Resuscitation↗

PubMed2004

Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing.

OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.

Adult↗

PubMed1997

The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group.

There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.

Developing Countries↗

PubMed2002

[Emergency medical training: the future of emergency care in Africa?].

The main goal of emergency medicine training is to teach the wide range of sciences and skills necessary to recognize and stabilize emergency situations. Emergency medicine training has proven highly effective in developed countries especially with regard to organization of survival medicine. This type of training is especially important in sub-Saharan Africa where there is a severe shortage of intensive care specialists and an almost total lack of other personnel qualified to manage life-threatening trauma and disease. Starting with the 1998 Nsam fire disaster in Yaounde, a number of situations have confirmed the seriously deficient state of resources for handling emergencies in Cameroon. In view of this situation a two-year study program in emergency medicine was proposed and introduced at the School of Medicine and Biomedical Sciences of the University of Yaounde I during the 2000/2001 academic year. The curriculum includes eight 40-hour didactic course modules and 800 hours of hands-on work in local hospitals and in France. Students undergo regular assessment of their scientific knowledge and practical competencies after each module. As additional prerequisites for the diploma, they must be certified in first aid and rescue and present a research paper. Despite the lack of faculty and teaching materials, this program is expected to increase the number of emergency medical care providers and improve access to high-quality emergency care services.

Africa↗

PubMed1992

[The emergency telephone number--the essential weak link in an emergency system. Prospective studies involving cardiac arrests observed by bystanders].

The first link in the "chain of survival" concept is the activation of the emergency medical system (EMS) by a bystander after recognition of cardiac arrest (CA) or its immediate prodrome. Our ongoing study is aimed at evaluating the current effectiveness of bystander EMS activation for all cases of CA in the city and area of Mainz. Methods. Starting February 1991, we began to prospectively examine collapse-intervention intervals in all cases of CA treated by our physician-manned ambulance. Precision voice recorders carried by the ambulance crews are activated and linked to the EMS dispatcher to time the arrival of the ambulance vehicle. Time intervals starting from the time of collapse are then reconstructed from the dispatcher's time and the tapes. The emergency phone number dialled initially by the bystander and the time of collapse in witnessed cardiac arrests are identified. RESULTS. Sixty-six CAs were witnessed and included in this study. In 20% of those cases, the number dialled initially by the bystander was 19222 (EMS dispatcher), in 38% 110 (police), and in 42% other numbers (family practitioners or their on-call service, fire department). The time interval, as median (25th percentile; 75th percentile), between collapse and receipt call by the emergency dispatchers was 4 min (2; 8) for all patients (n = 66), and 6.5 min (3; 12) whenever numbers other than emergency phone numbers were dialled. All following time intervals (start of BLS or ACLS procedures) showed differences (P less than 0.05) between the 110 or 19222 group [BLS: 8.5 min (4.8; 13.1) or 10 min (7.35; 12.1); ACLS: 11.3 min (9.1; 13.45) or 12.9 min (10.6; 21.5)] vs the group, in which other phone numbers were initially dialled [BLS: 15.25 min (9.25; 19.4); ACLS: 20.11 min (12.6; 28.3)]. The first ECG rhythm showed VF in 56% and 54% in case 110 and 19222 were dialled, but only in 32% in the other group. CONCLUSION. Even one single weak link in the "chain of survival" can lower overall survival rates. An indispensable, but apparently underrated component of an effective EMS includes an informed citizenry able to call swiftly for help. Lack of an unequivocal emergency number, well known and accepted by the citizens, produces confusion and delays. In our systems, the correct medical emergency phone number (19222) was dialled in 20% of the cases only, thus demonstrating clearly the lack of public awareness of this 5-digit number. In a higher percentage, the three-digit police number (110) was dialled. In cases where numbers other than emergency numbers were dialled (42%), the longest time intervals between collapse and receipt of call by the dispatchers occurred, associated with the longest time intervals until initiation of CPR and the lowest percentage of patients found in ventricular fibrillation. We conclude that establishment of a simple three-digit EMS phone number, preferentially Europe-wide, in combination with an intensification of public awareness, could be a vital step not only to reduce time intervals between collapse and CPR in our EMS system but also to improve survival.

Emergency Medical Service Communication Systems↗