Emergency Department Presentation
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2021 ◽  
Vol 50 (Supplement_1) ◽  
Catherine Chittleborough ◽  
Thomas Brown ◽  
Helena Schuch ◽  
Anna Kalamkarian ◽  
Rhiannon Pilkington ◽  

Abstract Background Experiencing socioeconomic disadvantage, poor health, or child maltreatment in early life has negative effects on child development. However, we know little about children who have good developmental outcomes despite experiencing adversity. Methods This study used de-identified, linked government administrative data from the South Australian Early Childhood Data Project: specifically Australian Early Development Census (AEDC) data for all South Australian born children in their first year of school in 2009, 2012 and 2015 (n = 47,179) and their corresponding birth, perinatal, school enrolment, hospital admission, emergency department presentation, public housing and child protection data. Latent class analyses constructed multidimensional measures of socioeconomic, health, and maltreatment adversities experienced from birth to age 5. Results Overall, 49.8% (95% CI 49.2-50.4) of children were on track on all five AEDC domains, but this ranged from 53.7% among children who did not experience high levels of adversity to 13.5% among children with high levels of all three adversities. Conclusions Among children who experienced high levels of two or three early adversity types, approximately 1 in 5 were developmentally on track. Understanding characteristics of these children who thrive, against the odds, will help identify intervention opportunities to improve child development. Key messages Compared with children who did not experience high levels of adversity, each additional adversity reduced the likelihood of being developmentally on track by approximately 10% to 15%. Children experiencing socioeconomic or maltreatment adversity were less likely to be developmentally on track than children experiencing health adversity.

BMJ Open ◽  
2021 ◽  
Vol 11 (9) ◽  
pp. e049235
Jonathan Clarke ◽  
Kelsey Flott ◽  
Roberto Fernandez Crespo ◽  
Hutan Ashrafian ◽  
Gianluca Fontana ◽  

ObjectivesTo determine the safety and effectiveness of home oximetry monitoring pathways for patients with COVID-19 in the English National Health Service.DesignRetrospective, multisite, observational study of home oximetry monitoring for patients with suspected or proven COVID-19.SettingThis study analysed patient data from four COVID-19 home oximetry pilot sites in England across primary and secondary care settings.ParticipantsA total of 1338 participants were enrolled in a home oximetry programme across four pilot sites. Participants were excluded if primary care data and oxygen saturations at rest at enrolment were not available. Data from 908 participants were included in the analysis.InterventionsHome oximetry monitoring was provided to participants with a known or suspected diagnosis of COVID-19. Participants were enrolled following attendance to emergency departments, hospital admission or referral through primary care services.ResultsOf 908 patients enrolled into four different COVID-19 home oximetry programmes in England, 771 (84.9%) had oxygen saturations at rest of 95% or more, and 320 (35.2%) were under 65 years of age and without comorbidities. 52 (5.7%) presented to hospital and 28 (3.1%) died following enrolment, of which 14 (50%) had COVID-19 as a named cause of death. All-cause mortality was significantly higher in patients enrolled after admission to hospital (OR 8.70 (2.53–29.89)), compared with those enrolled in primary care. Patients enrolled after hospital discharge (OR 0.31 (0.15–0.68)) or emergency department presentation (OR 0.42 (0.20–0.89)) were significantly less likely to present to hospital than those enrolled in primary care.ConclusionsThis study finds that home oximetry monitoring can be a safe pathway for patients with COVID-19; and indicates increases in risk to vulnerable groups and patients with oxygen saturations <95% at enrolment, and in those enrolled on discharge from hospital. Findings from this evaluation have contributed to the national implementation of home oximetry across England.

Rajan Choudhary ◽  
Madhumita Gupta ◽  
Shahidul Haq ◽  
Wareth Maamoun

<p class="abstract"><strong>Background: </strong>Coronavirus disease 2019 (COVID 19) has created an immense strain on the NHS. During the height of the pandemic, trauma services were affected by redeployment, reduced theatre capacity and staff illness, and COVID BOAST guidelines were introduced.</p><p class="abstract"><strong>Methods: </strong>This retrospective study aimed to evaluate the standards of management of open fractures of the lower limb at a Major Trauma Centre in the United Kingdom during the COVID-19 pandemic and compare the same with the pre-pandemic period. Patient demographics, mechanism of injury, timing and mechanism of initial debridement and definitive soft tissue and skeletal fixation were noted. Outcomes including duration of hospital stay, 30 day and 1 year mortality were also assessed.</p><p class="abstract"><strong>Results: </strong>There was an overall 21% reduction in admissions with open lower limb fractures during the pandemic period with a 48% reduction during the first lockdown. There was a significant reduction in time taken from Emergency Department presentation to first debridement as well as a notable increase in operating outside of regular theatre hours. There was little difference in operative technique used for skeletal or soft tissue management at initial and definitive surgery, though fewer cases were performed as a two stage procedure. There was no difference in amputation rate in the two years. Length of stay was reduced from 21 days to 17, and 30 day mortality remained the same.</p><p class="abstract"><strong>Conclusions:</strong> Our study shows this Major Trauma Centre was able to provide a trauma service in accordance to the BOAST4 guidelines despite the increased pressures of the COVID-19 pandemic.</p>

2021 ◽  
Vol Publish Ahead of Print ◽  
Quazim A. Alayo ◽  
Abayomi O. Oyenuga ◽  
Adeyinka C. Adejumo ◽  
Vijay Pottathil ◽  
Damanpreet Grewal ◽  

2021 ◽  
Vol 36 (Supplement_1) ◽  
S Boyd ◽  
K O’Donoghue ◽  
S Meaney

Abstract Study question Has the COVID–19 pandemic and public health guidance impacted referrals, outcome and management of early pregnancy in the emergency room? Summary answer COVID–19 changed the way in which women sought guidance and accessed services in early pregnancy. What is known already Spontaneous miscarriage is the most common complication of pregnancy1. Experiencing an early pregnancy loss is often an unexpected and difficult time that can be physically traumatising2. A previous study looking at the experience of a miscarriage from both the female and male point of view identified that long waiting times surrounded by other pregnant women in the Emergency Department (ED) was particularly difficult part of the experience2. The COVID–19 pandemic had a significant impact on both hospital and community services. Public health advice also changed the way women accessed healthcare. Study design, size, duration Retrospective audit was performed over two six-month periods – July to December 2019 and March to August 2020. Two groups of data were collected; women who contacted the ED with concerns related to early pregnancy (under thirteen weeks gestation) and those who attended the ED with the same complaints. Information was cross referenced to see how many women contacted the ED prior to arrival and what, if any advice was given. Participants/materials, setting, methods All women under thirteen weeks gestation with a complaint of bleeding per vaginum (PV) or pain related to early pregnancy who presented to the ED in a large tertiary maternity unit were included in the audit. All women meeting the same criteria who contacted the ED by telephone were also included. Main results and the role of chance Over the twelve months of data collection, 1274 women had their first visit to the ED. There were 270 further visits within the early pregnancy period recorded for the same cohort of women. Additionally, 1452 phone calls were recorded. There was a 38% (n = 293) decrease in women attending the emergency room in early pregnancy in 2020 during the first wave of COVID–19. There was a 16% (n = 110) increase in women contacting the ED for advice in early pregnancy in the same period in 2020. Women were more like likely to have been referred to the ED by their General Practitioner (GP) (OR 0.62, 95%CI 0.48–0.80) and to have phoned in advance of arrival (OR 1.55, 95%CI 1.17–2.04) in 2020. They were also more likely to have already had a previous ultrasound scan in the current pregnancy (OR 0.64, 95%CI 0.48–0.93). There was a significantly shorter waiting time for an appointment in the early pregnancy clinic in 2020 compared with 2019 (3.5 days versus 2.4 days, p = 0.002). There was no change in the number of women admitted (OR 1.19, 95%CI 0.81–1.74). Limitations, reasons for caution Single centre audit. Pregnancies only followed to booking visit/dating scan and outcome noted at that stage. Wider implications of the findings: The COVID–19 pandemic highlighted the need for more education around early pregnancy. Easily accessible information about local early pregnancy services gives women autonomy. Phone triage allowing referral of women to appropriate services, reduces ED visits. Standard training in early pregnancy ultrasound could reduce follow up referrals and admission rates. Trial registration number Not applicable

2021 ◽  
Vol 5 (7) ◽  
Stephen Brennan ◽  
Saadah Sulong ◽  
Matthew Barrett

Abstract Background Left ventricular pseudoaneurysm (LVP) is an uncommon but serious mechanical complication of acute myocardial infarction (AMI). The immediate medical complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are well recognized, but its indirect effect on patients and healthcare systems is potentially less perceivable. Case summary In this report, a 72-year-old man who was anxious about attending hospital during the SARS-CoV-2 pandemic was eventually found to have a total right coronary artery occlusion after a delayed emergency department presentation. He ultimately developed severe symptomatic heart failure and cardiac magnetic resonance imaging (CMR) revealed that a large LVP with concomitant severe ischaemic mitral regurgitation had evolved from his infarct. The patient was successfully discharged home after the surgical replacement of his mitral valve and repair of his LVP. Discussion This case highlights a salient downstream effect of Coronavirus disease 2019 (COVID-19): the delay in presentation, diagnosis, and management of common treatable conditions such as AMI. It also underscores the importance of non-invasive multimodal imaging on the timely identification of the mechanical complications of AMI. In particular, CMR can play a crucial role in the characterization and management of LVP.

2021 ◽  
Vol 11 (1) ◽  
Andrew R. Moore ◽  
Jonasel Roque ◽  
Brian T. Shaller ◽  
Tola Asuni ◽  
Melissa Remmel ◽  

AbstractSeveral clinical calculators predict intensive care unit (ICU) mortality, however these are cumbersome and often require 24 h of data to calculate. Retrospective studies have demonstrated the utility of whole blood transcriptomic analysis in predicting mortality. In this study, we tested prospective validation of an 11-gene messenger RNA (mRNA) score in an ICU population. Whole blood mRNA from 70 subjects in the Stanford ICU Biobank with samples collected within 24 h of Emergency Department presentation were used to calculate an 11-gene mRNA score. We found that the 11-gene score was highly associated with 60-day mortality, with an area under the receiver operating characteristic curve of 0.68 in all patients, 0.77 in shock patients, and 0.98 in patients whose primary determinant of prognosis was acute illness. Subjects with the highest quartile of mRNA scores were more likely to die in hospital (40% vs 7%, p < 0.01) and within 60 days (40% vs 15%, p = 0.06). The 11-gene score improved prognostication with a categorical Net Reclassification Improvement index of 0.37 (p = 0.03) and an Integrated Discrimination Improvement index of 0.07 (p = 0.02) when combined with Simplified Acute Physiology Score 3 or Acute Physiology and Chronic Health Evaluation II score. The test performed poorly in the 95 independent samples collected > 24 h after emergency department presentation. Tests will target a 30-min turnaround time, allowing for rapid results early in admission. Moving forward, this test may provide valuable real-time prognostic information to improve triage decisions and allow for enrichment of clinical trials.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18577-e18577
Christopher Noel ◽  
Antoine Eskander ◽  
Rinku Sutradhar ◽  
Alyson Mahar ◽  
Simone Vigod ◽  

e18577 Background: Psychological distress is a key construct of patient-centred cancer care. While an increased risk of suicide for cancer patients has been reported, more frequent consequences of distress after a cancer diagnosis, such as non-fatal self-injury (NFSI), remain largely unknown. We examined the risk for NFSI after a cancer diagnosis. Methods: Using linked administrative databases we identified adults diagnosed with cancer between 2007-2019. Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed accounting for the competing-risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. Results: Of 806,910 included patients, 2,482 had NFSI and 182 died by suicide. 5-year cumulative incidence of NFSI was 0.27% [95%CI 0.25-0.28%]. After adjusting for key confounders, prior severe psychiatric illness whether requiring inpatient care (sub-distribution hazard ratio (sHR) 12.6, [95% CI 10.5-15.2]) or outpatient care (sHR 7.5, 95% CI 6.48-8.84), and prior self-injury (sHR 6.6 [95% CI 5.5-8.0]) were associated with increased risk of NFSI. Young adults (age 18-39) had the highest NFSI rates, relative to individuals >70 (sHR 5.4, [95% CI 4.5-6.5]). The magnitude of association between prior severe psychiatric illness and NFSI was greatest for young adults (interaction term p < 0.01). Certain cancer subsites were also at increased risk, including head and neck (sHR1.52, [95%CI 1.19-1.93]). Conclusions: Patients with cancer have higher incidence of NFSI than suicide after diagnosis. Younger age, prior severe psychiatric illness, and prior self-injury were independently associated with NFSI. These exposures act synergistically, placing young adults with a prior mental health history at greatest risk for NFSI events. Those factors should be used to identify at-risk patients for psycho-social assessment and intervention.

Fiona McNicholas ◽  
Sorcha Parker ◽  
Elizabeth Barrett

Introduction: An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres. Methods: Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored. Results: Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of 39 females (66%) with a mean age of 13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting (n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission rates and length of stay. Discussion: Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.

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