Social work in a hospital emergency department

This paper describes how a Hospital Social Work Department's Emergency Team has attempted to provide a crisis and out-of-hours service to its Emergency Department. Through a staffing commitment to extensive evening and weekend cover, the Emergency Team's social worker is able to provide an immediate intervention and assessment service to problems. This has resulted in early detection and treatment of the non-medical aspects of a patient's problem and appropriate referral to other agencies for longer-term follow-up.

Emergency Handling in MICS based Body Area Network

Body Area Network, a new wireless networking paradigm, promises to revolutionize the healthcare applications. A number of tiny sensor nodes are strategically placed in and around the human body to obtain physiological information. The sensor nodes are connected to a coordinator or a data collector to form a Body Area Network. The tiny devices may sense physiological parameters of emergency in nature (e.g. abnormality in heart bit rate, increase of glucose level above the threshold etc.) that needs immediate attention of a physician. Due to ultra low power requirement of wireless body area network, most of the time, the coordinator and devices are expected to be in the dormant mode, categorically when network is not operational. This leads to an open question, how to handle and meet the QoS requirement of emergency data when network is not operational? Emergency handling becomes more challenging at the MAC layer, if the channel access related information is unknown to the device with emergency message. The aforementioned scenarios are very likely scenarios in a MICS (Medical Implant Communication Service, 402-405 MHz) based healthcare systems. This paper proposes a mechanism for timely and reliable transfer of emergency data in a MICS based Body Area Network. We validate our protocol design with simulation in a C++ framework. Our simulation results show that more than 99 p ercentage of the time emergency messages are reached at the coordinator with a delay of 400ms.

Análisis de la interferencia inducida en el electrocardiograma y señal de impedancia por compresiones torácicas sobre un maniquí.

[EN]This paper presents a project within that research field. The project consists on the development of an experimental environment comprised by a sensorized practice manikin and a management software system. Manikin model allows the simulation of cardiac arrest episodes on laboratory settings. The management software system adds the capacity to compute and analyze the characteristics of the artifact induced on the electrocardiogram and the thoracic impedance signals by chest compressions during cardiopulmonary resuscitation due to variations of the electrode-skin interface. The main reason for choosing this kind of model is the impossibility to use real people because of the risk of thoracic injuries during chest compression. Moreover, this platform could be used for training in reanimation techniques for real situations. Even laypeople with minimal training can perform cardiopulmonary resuscitation. This can reduce the response time to an emergency while the healthcare personnel arrives, which is key to improve outcomes, since with every minute the chances of survival decrease approximately 10%. It is not necessary to have medical knowledge to perform cardiopulmonary resuscitation, which could increase chances of survival for a patient with an early reanimation since In this context, this paper details the technique solution for the manikin sensorisation to acquire the electrocardiogram, the impedance signal measured between the defibrillation pads placed on the patient’s chest, the compression depth, the compression force and the acceleration experienced by the chest in the three orthogonal axes. Moreover, it is possible to inject a previously recorded electrocardiogram signal.

Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments

Background: Limited information is available about predictors of short-term outcomes in patients with exacerbation of chronic obstructive pulmonary disease (eCOPD) attending an emergency department (ED). Such information could help stratify these patients and guide medical decision-making. The aim of this study was to develop a clinical prediction rule for short-term mortality during hospital admission or within a week after the index ED visit. Methods: This was a prospective cohort study of patients with eCOPD attending the EDs of 16 participating hospitals. Recruitment started in June 2008 and ended in September 2010. Information on possible predictor variables was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up. Main short-term outcomes were death during hospital admission or within 1 week of discharge to home from the ED, as well as at death within 1 month of the index ED visit. Multivariate logistic regression models were developed in a derivation sample and validated in a validation sample. The score was compared with other published prediction rules for patients with stable COPD. Results: In total, 2,487 patients were included in the study. Predictors of death during hospital admission, or within 1 week of discharge to home from the ED were patient age, baseline dyspnea, previous need for long-term home oxygen therapy or non-invasive mechanical ventilation, altered mental status, and use of inspiratory accessory muscles or paradoxical breathing upon ED arrival (area under the curve (AUC) = 0.85). Addition of arterial blood gas parameters (oxygen and carbon dioxide partial pressures (PO2 and PCO2)) and pH) did not improve the model. The same variables were predictors of death at 1 month (AUC = 0.85). Compared with other commonly used tools for predicting the severity of COPD in stable patients, our rule was significantly better. Conclusions: Five clinical predictors easily available in the ED, and also in the primary care setting, can be used to create a simple and easily obtained score that allows clinicians to stratify patients with eCOPD upon ED arrival and guide the medical decision-making process.

Medical education as moral formation: an Aristotelian account of medical professionalsim.

The medical professionalism movement, bolstered by many influential medical organizations and institutions, has in the last decade produced a number of conceptual definitions of professionalism and a number of concrete proposals for its measurement and teaching. These projects, however laudable, are misguided when they treat professionalism as a unitary descriptive concept rather than as a contested and therefore primarily evaluative one; when they conceive professionalism as a domain of medical practice separable in principle from other domains; and when they treat professionalism as, in principle, a specifiable goal or product of sufficiently well designed educational curricula. The logic of professionalism-as-product corresponds to the logic of techne (art or practical skill) in Aristotle's Nicomachean Ethics. Aristotle provides a cogent argument, however, that the moral excellences denoted by "professionalism" cannot be "produced" or even prespecified in the concrete; rather, they must be acquired through long practice under the careful concrete guidance of teachers who themselves embody these moral excellences. Phronesis (practical wisdom) rather than techne must therefore be the guiding logic of educational initiatives in medical professional formation, with particular emphasis on close mentorship and on the moral character both of students and of those who teach them.

Analysis of traumatic injuries presenting to a referral hospital emergency department in Moshi, Tanzania.

BACKGROUND: Injuries represent a significant and growing public health concern in the developing world, yet their impact on patients and the emergency health-care system in the countries of East Africa has received limited attention. This study evaluates the magnitude and scope of injury related disorders in the population presenting to a referral hospital emergency department in northern Tanzania. METHODS: A retrospective chart review of patients presenting to the emergency department at Kilimanjaro Christian Medical Centre was performed. A standardized data collection form was used for data abstraction from the emergency department logbook and the complete medical record for all injured patients. Patient demographics, mechanism of injury, location, type and outcomes were recorded. RESULTS: Ten thousand six hundred twenty-two patients presented to the emergency department for evaluation and treatment during the 7-month study period. One thousand two hundred twenty-four patients (11.5%) had injuries. Males and individuals aged 15 to 44 years were most frequently injured, representing 73.4% and 57.8%, respectively. Road traffic injuries were the most common mechanism of injury, representing 43.9% of injuries. Head injuries (36.5%) and extremity injuries (59.5%) were the most common location of injury. The majority of injured patients, 59.3%, were admitted from the emergency department to the hospital wards, and 5.6%, required admission to an intensive care unit. Death occurred in 5.4% of injured patients. CONCLUSIONS: These data give a detailed and more robust picture of the patient demographics, mechanisms of injury, types of injury and patient outcomes from similar resource-limited settings.

Does first aid have a place in the medical curriculum? A survey of medical students

Introduction: When a medical emergency occurs in the prehospital environment, there is an expectation from the general public for medical students to offer assistance with a similar level of competence as qualified doctors. However, the question is raised; do medical students have sufficient training in first aid skills to fulfil the role expected of them?

Prior to the publication of the latest version of Tomorrow’s Doctors by the UK General Medical Council, a student selected component (SSC) in first aid was delivered at the medical school in Queen’s University Belfast (QUB), Northern Ireland. The overwhelming popularity of this SSC prompted a desire to investigate and understand students’ experiences of first aid.

Aim: To identify first and second year medical students’ knowledge of, and attitudes towards, first aid and their expectations of the medical curriculum.

Methods: A questionnaire was delivered using TurningPoint Audience Response System® during the second semester of the 2008 - 2009 academic year to all first and second year medical students at QUB.

Results: Less than half of the students felt that they had a good level of first aid knowledge, a third would feel confident helping in an emergency and only 10% would be confident leading an emergency situation. The vast majority of students believed first aid is beneficial, that the general public expect medical students to have the knowledge to handle an emergency situation, and that a full first aid course should be included in the core medical curriculum at an early stage. They did not believe it should be a pre-requisite for medical school.

Conclusion: Only a small proportion believed their first aid knowledge adequate. An overwhelming proportion believed that first aid training is beneficial and that the public expect competency in managing emergencies. This study clearly demonstrates students’ need and desire for first aid training in the core medical curriculum at an early stage and to the highest training level possible.

A Bayesian network hybrid model for representing accident and emergency waiting times

The paper introduces a new modeling approach that represents the waiting times in an accident and emergency (A&E) department in a UK based national health service (NHS) hospital. The technique uses Bayesian networks to capture the heterogeneity of arriving patients by representing how patient covariates interact to influence their waiting times in the department. Such waiting times have been reviewed by the NHS as a means of investigating the efficiency of A&E departments (emergency rooms) and how they operate. As a result activity targets are now established based on the patient total waiting times with much emphasis on trolley waits.

CoWiSMoN: A Framework for Cognitive Wireless Sensor Mobile Network System for Emergency Rescue Management

One of the crucial aspects of disaster management of emergency situations is the early assessment of needs and damages. In most disaster situations, higher fatality and increased casualty results from lack of access to timely available emergency services rather than the initial disaster itself. This is usually caused by lack of access to the affected area in order to properly assess the situation for relevant and urgent measures. Cognitive wireless sensor networks provide an opportunity to overcome this situation especially through interconnection via mobile systems. This paper presents a cognitive wireless sensor mobile networks-based framework (CoWiSMoN), designed to offer real-time emergency services to victims and rescue personnel in event of disasters. Critical issues underlying the implementation of such a system are discussed and analyzed.

Incorporation of spiritual care as a component of healthcare and medical education: comparison of viewpoints of healthcare providers from a rural community hospital in Uganda with those of medical students from United Kingdrom

This study addresses cultural differences regarding views on the place for spirituality within healthcare training and delivery. A questionnaire was devised using a 5-point ordinal scale, with additional free text comments assessed by thematic analysis, to compare the views of Ugandan healthcare staff and students with those of (1) visiting international colleagues at the same hospital; (2) medical faculty and students in United Kingdom. Ugandan healthcare personnel were more favourably disposed towards addressing spiritual issues, their incorporation within compulsory healthcare training, and were more willing to contribute themselves to delivery than their European counterparts. Those from a nursing background also attached a greater importance to spiritual health and provision of spiritual care than their medical colleagues. Although those from a medical background recognised that a patient’s religiosity and spirituality can affect their response to their diagnosis and prognosis, they were more reticent to become directly involved in provision of such care, preferring to delegate this to others with greater expertise. Thus, differences in background, culture and healthcare organisation are important, and indicate that the wide range of views expressed in the current literature, the majority of which has originated in North America, are not necessarily transferable between locations; assessment of these issues locally may be the best way to plan such training and incorporation of spiritual care into clinical practice.

Persistent luminescence of SrAl2O4:Ce(III), Dy, Eu nanotubes, nanowires and core-shells for people with disabilities: nano-emergency

Este estudo transversal está focado na propriedade de luminescência persistente do aluminato de estrôncio co-dopado com cério (III), disprósio (III) e európio (II), SrAl2O4:Ce3+, Dy3+, Eu2+, em sistemas de sinalização de áreas de risco e emergências para pessoas com deficiências. Na área da ciência e engenharia dos materiais, foram desenvolvidos novos materiais com características nanométricas, nanotubos, nanoarames e nanobastões luminescentes de SrAl2O4:Ce3+, Dy3+, Eu2+ para aplicações na área da reabilitação e acessibilidade de pessoas com deficiências. Os nanotubos foram obtidos a partir de micro- e nano-partículas precursoras sintetizadas por reacção do estado-sólido e tratamento térmico de recozedura (1273-1473 K). Os nanoarames e nanobastões foram preparados por moagem, sonificação e recozedura (373 K). Novas nanocápsulas de aluminatos luminescentes dopados com cério (III) e encapsulados com TiO2 foram criadas de modo a obter-se materiais multifuncionais, designadamente com acção fotocatalítica antimicrobiana, antibacteriana e resistência à água. Tais aluminatos podem ser amplamente aplicados como superfícies higiénicas, auto-limpantes, em biomateriais, no domínio de medicamentos antibióticos, na formulação de vacinas, e com ênfase à aplicação em cerâmicas fotoluminescentes. As metodologias de obtenção de tais nanoestruturas de aluminato de estrôncio dopado com cério (III) e do seu encapsulamento, desenvolvidas no âmbito desta tese, são aplicáveis a diversos aluminatos dopados com outros iões lantanídeos (Ln consiste em La, Ce, Pr, Nd, Pm, Sm, Eu, Gd, Tb, Dy, Ho, Er, Yb, Tm ou Lu) com a fórmula M(1-x-y)N2O4:Cex, Lny, onde M é Be, Mg, Ca, Sr ou Ba. Na área da oftalmologia, foi desenvolvido um equipamento médico para o diagnóstico de biofuncionalidade das células retinais fotoreceptoras, e como suporte à telemedicina oftalmológica. Este equipamento foi utilizado para realizar testes de visão cromática FM100HUE em fundo branco/preto para a personalização de materiais luminescentes. Os resultados demonstraram uma biofuncionalidade celular à visibilidade fotópica das cores em fundo preto superior no grupo de tratamento, composto por pessoas com retinopatia diabética (n=38), em comparação ao grupo de referência (n=38). Estes resultados sugerem a recomendação de materiais com fotoluminescência persistente (λem=485-555 nm), incluindo SrAl2O4:Ce3+, Dy3+, Eu2+, para o referido grupo de tratamento, em sinalização de emergência e em ambientes de baixa iluminação. Na área da arquitectura, foi proposta uma nova aplicação dos referidos nanomateriais luminescentes à base de SrAl2O4:Ce3+, Dy3+, Eu2+ em cerâmica de revestimento, tendo em vista a sua boa visibilidade e uso por pessoas com deficiências. Novos pavimentos, cerâmicos, fotoluminescentes, foram desenhados com propriedades multisensoriais (contraste táctil, sonoro e visual) e antimicrobianas, para pessoas portadoras de deficiências utilizarem, no escuro, com a prioridade de salvar vidas em emergências. Tais pisos, com relevos, podem ser combinados de modo a compor um sistema exclusivo de sinalização fotoluminescente multisensorial que possibilita a rápida evacuação mediante o uso de auxílios de mobilidade (e.g. bengala, cadeira de rodas, andadores, muletas). A solução integrada de tais inovações que potencializa a propriedade de luminescência persistente de SrAl2O4:Ce3+, Dy3+, Eu2+ de modo acessível para as pessoas com deficiências, pode contribuir para salvar vidas, no escuro, em emergências.

Risk Modelling Framework for Emergency Hospital Readmission, Using Hospital Episode Statistics Inpatient Data

The objective of this study was to develop, test and benchmark a framework and a predictive risk model for hospital emergency readmission within 12 months. We performed the development using routinely collected Hospital Episode Statistics data covering inpatient hospital admissions in England. Three different timeframes were used for training, testing and benchmarking: 1999 to 2004, 2000 to 2005 and 2004 to 2009 financial years. Each timeframe includes 20% of all inpatients admitted within the trigger year. The comparisons were made using positive predictive value, sensitivity and specificity for different risk cut-offs, risk bands and top risk segments, together with the receiver operating characteristic curve. The constructed Bayes Point Machine using this feature selection framework produces a risk probability for each admitted patient, and it was validated for different timeframes, sub-populations and cut-off points. At risk cut-off of 50%, the positive predictive value was 69.3% to 73.7%, the specificity was 88.0% to 88.9% and sensitivity was 44.5% to 46.3% across different timeframes. Also, the area under the receiver operating characteristic curve was 73.0% to 74.3%. The developed framework and model performed considerably better than existing modelling approaches with high precision and moderate sensitivity.

Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents [Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?].

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.