Emergency Care

ones which started working on it ahead of times: so, let’s look back at it. Those who acted early, differentiating routes within the Emergency Department (EDpt), creating different areas with varying intensity of care; those who were quick in converting areas of mid-intensive care into Sub-Intensive Care Units (SICU) where to allocate only patients in need of non-invasive ventilation; those who quickly converted internal medicine areas into Covid-19 medicine ones; those who converted SICU into Intensive Care Units (ICU); those who created new ICUs; ultimately, those who adapted hospitals to handle both the extraordinary pressure that hit Emergency Rooms (ERs) and many critical patients (yellow and red codes) still coming in, keeping ERs decongested and therefore able to work safely, guaranteed a fair treatment for all patients and probably improved the prognosis. In reality, as tragically recounted in a May 2020 article on NEJM,1 this was not the case. Some hospitals in Lombardy and...

Emergency departments (EDs) are increasingly used for patients at the end of life stage of their diseases worldwide, even if they do not have acute and potentially treatable conditions. Moreover, an increasingly shortage of hospital beds, in spite of the wellrecognized ageing of the population, has led to a progressive prolongation of the average length of stay (LOS) time in the vast majority of Italians EDs. Therefore, the aim of this study was to describe the trend of ED non-traumatic deaths in 11 Italians EDs, and to correlate these deaths with the medium length of stay in the same EDs. All cases classified as “died during ambulance transfer or while in the ED” have been retrieved from the hospital database of the 11 participating EDs, from January 1st 2007 to December 31st 2016, with the exclusion of traumatic events. The average LOS in minutes of the seven hospitals that could provide this information was then calculated. A continuously increasing number of ED deaths was observ...

Emergency Room (ER) can be considered as a High Reliability Organization expected to guarantee reliability despite facing hectic and unpredictable events. To achieve this status, ER should invest on the management style of Organizational Mindfulness, focused on anticipation and containment of errors. The aim of this exploratory research was to investigate how Organizational Mindfulness occurs in Italian ERs and what is the role of Safety Culture and Work Engagement in predicting Organizational Mindfulness measured with an ad hoc questionnaire. Results show how the communal sphere of Safety Culture seems a better predictor of Organizational Mindfulness than the individual sphere of Work Engagement.

The mainstay of patient-oriented laboratory testing in emergency settings entails selecting a number and the type of tests according to valid criteria of appropriateness. Since the pattern of urgent tests requesting is variable across different institutions, we designed a joined survey between the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC) for reaching tentative consensus about the most informative diagnostic tests in emergency settings. A survey, containing the most commonly ordered urgent laboratory tests and the relative clinical indications, was disseminated to eight relevant members of AcEMC and eight relevant members of SIBioC. All contributors were asked to provide numerical scores for the different laboratory parameters, where 1 indicated "strongly recommended", 2 "recommended in specific circumstances", and 3 "strongly discouraged". The mean results of ...

Early recognition of ECG signs of acute coronary syndrome is essential for prompt treatment. But presentation with atypical ECG changes constitute a diagnostic challenge. We here report a case of 23-year-old male who presented with chest pain having atypical ECG changes with hyper-acute T waves called de Winters T wave. This is a rare presentation of patient with acute Left Anterior Descending artery occlusion. Some authors propose that de Winters pattern should be considered as “STEMI Equivalent”.

Esophageal perforation is a welldefined and severe clinical condition. The associated mortality rates range between 5% and 40% and are worsened by delayed diagnosis. Rapid diagnosis and therapy provide the best chance for survival; however, a delay in diagnosis is common, resulting in substantial morbidity and mortality. There are several aetiologies of esophagus perforation. Most esophageal ruptures are secondary to medical instrumentation. Other causes are Boerhaave syndrome, toxic ingestions and radiation, foreign body ingestion, penetrating trauma, and, rarely, blunt chest trauma. We reported the clinical management and the diagnostic work-up case of esophagus perforation due to the foreign body ingestion.

Lung ultrasound is a reasonable tool for detection of manifestations of COVID-19, to facilitate the division of patients flow of infected with SARS-CoV-2 from those affected by other pathologies. Often, a reason for the incorrect separation of the flows is the possibility of false-negative rRT-PCR results. We aimed to evaluate the advantages of performing Lung Ultrasound (LUS) in patients with a negative swab, to confirm the suspicious of COVID-19 at the bedside, according to the recent findings of typical lung ultrasound lesions of COVID19 related pneumonia. We analyzed 11 non-critical patients admitted to Emergency Department in the Internal Medicine ward, during outbreak, as Covid-19 negative patients affected by pneumonia. The result of the ultrasound findings conditioned the consequent allocation of the patient. 9/11 patients had typical LUS findings for COVID-19, but only 3/11 patients had a second positive nasopharyngeal swab, and 2/11 had positive swab on pleural fluid. 6/11...

In Italy emergency physicians are the front line of care for patients with medical conditions such as trauma, heart attacks, strokes or psychiatric disorders. Triage represents the first clinical contact with the person to determine urgency of care, and includes initial risk assessment and determination of observation level. It is necessary to undertake mental health triage for all service users on entry to the Emergency Department (ED), alongside physical health triage. The recourse to emergency services for psychiatric complaints is increasing and ED providers are often the first contact a patient will have with psychiatric care. The organization of Italian EDs is constantly evolving under the pressure of various external forces (population aging, increasing use of new substances, immigration, choices of economic policy, and technological development). The psychiatric emergency service contact represents a key to addressing the presenting problem and it is a critical link for cont...

The most common diagnoses of pelvic/supra-pubic pain are related to uterine, gonadal, renal, and bladder complications. Hydrocele of the canal of Nuck is a rare cause of inguinal swelling in women, which occurs due to a patent processus vaginalis. The canal of Nuck typically closes in infancy, however, in some women, the canal of Nuck remains patent, allowing for the development of canal of Nuck cysts or indirect inguinal hernias. Until now, about 400 cases of this illness have been reported worldwide. Clinically, these cysts are usually fluctuant, painless, or may present locally painful masses in the labia or inguinal regions which are not reducible; we report the case of a young female which was characterized by persistent suprapubic pain in which the diagnosis initially made by ultrasonography was further confirmed by contrast-enhanced computed tomography, surgery and pathological examination.

Abstract: Hospital today are under increasing pressure to increase the quality and efficiency of patient identification and monitoring procedures. Most patient health records are stored in separate systems and there are still huge paper trails of records that health-care providers must keep to comply with different regulations. This paper proposes an RFID-based system (named SIMOPAC) that integrates RFID and multi-agent technologies in health care in order to make patient emergency care as efficient and risk-free as possible, by providing doctors with as much information about a patient as quickly as possible. Every hospital could use SIMOPAC with their existing system in order to promote patient safety and optimize hospital workflow. In this paper we will concentrate on the RFID technology and how it could be used in emergency care in order to identify patients and to achieve real time information concerning the patients ’ biometric data, which might be used in different points of ...

Background: Information and communication technologies (ICTs) are often proposed as ‘technological fixes ’ for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare. Methods: We undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis. Results: Our data comprise...

Starting from 1st case in Italy, on February 20th, 2020, CO-rona VI-rus D-isease 2019 (COVID-19) pandemic spread to whole Italian territory, with different regional distribution Tuscany has been classified as medium diffusion area (40-100 cases/100000 inhabitants) In this context, all healthcare structures reviewed their organization to meet new needs Our study's objectives were description of organizational model outlined to safely manage Emergency Department (ED) and analysis of patients' flows within Hospital of Pisa during pandemic The ED has been reorganized with dedicated areas for examination and waiting for tests results A similar reduction (-62%) of ED accesses comparing to the same period of 2019 and the previous months of 2020 was observed Hospital Task Force arranged for progressive activation of Units by modules, according to territorial needs From the beginning of March to the end of April 2020, 315 COVID-19 patients were hospitalized Overall, a 45% reduction i...

Early recognition of ECG signs of acute coronary syndrome is essential for prompt treatment. But presentation with atypical ECG changes constitute a diagnostic challenge. We here report a case of 23-year-old male who presented with chest pain having atypical ECG changes with hyper-acute T waves called de Winters T wave. This is a rare presentation of patient with acute Left Anterior Descending artery occlusion. Some authors propose that de Winters pattern should be considered as “STEMI Equivalent”.

ABSTRACT Technology has been able to provide the tools for swift and rapid treatment but is our human counterpart equally tuned. As the growing need of doctors is unable to compete with ever prolific population growth, the development of stand-alone systems for providing immediate health care or First Aid has become a dire need. To add to this dilemma, acute shortage of health care professionals in this field has led to major outsourcing of human resources from villages, slums and rural areas. This massive inflow of partially or completely untrained health care assistants has only added oil to this growing flame of unresponsive and crude immediate health care competence. The solution we propose in this paper is the development and integration of unique case-based statistical data collection with autonomous emergency alerts and temporary preventive measures. Thus restricting the patient’s dependence on doctors or nurses might not be in the position to provide the best treatment due to sudden escalating unforeseen conditions.

To investigate if Brain Natriuretic Peptide (BNP) and highsensitivity troponin I predict significant arrhythmia, symptomatic significant arrhythmia and 90-day death and/or Major Adverse Cardiac Event in Emergency Department (ED) unexplained syncope patients investigated with a 14-day ambulatory electrocardiogram (ECG) recorder. Single-centre, prospective, cohort study. Patients 16 years or over presenting within 6 hours of an episode of unexplained syncope were fitted with an ambulatory ECG recorder (Zio® XT monitor) and had high-sensitivity troponin I and BNP measured on ED admission and 3 hours later. Between 17/11/2015 and 13/06/2017, 86 patients were recruited. 24 had significant arrhythmia, 9 symptomatic significant arrhythmia and 26 patients had death and/or Major adverse cardiac events by 90 days. BNP at admission, three hours and change in BNP and high-sensitivity troponin I at three hours were associated with significant arrhythmia and serious outcome. BNP>20pg/mL and/or...

Cement extravasation is a rather common complication of vertebroplasty, which can be observed in up to 30-40% of patients undergoing this procedure, further associated with venous leakage occurring in up to 24% of cases. Pulmonary embolism may eventually develop once the cement migrates within the pulmonary artery, and is the most common complication of cement extravasation (involving ~4.6% of patients). Intra-cardiac cement embolism is considerably less frequent, but is a potentially fatal complication, mostly managed with cardiac surgery. We describe here a rare case of near-fatal cardiac cement embolism, with a large fragment perforating the right ventricle and reaching the pericardium, who presented to the Emergency Department (ED) for syncope. The patient, who displayed this severe complication after a vertebroplasty procedure performed for osteoporotic compression fracture, needed cardiac surgery.

Since pain perception is highly subjective and culturally mediated, its objective evaluation remains difficult. Nevertheless, pain measurement should ideally be a part of the assessment of patients in order to plan adequate pain relief. Several scales have been proposed for pain measurement, being the numerical rating scale (NRS) the most widely used, often at triage time. NRS have demonstrated acceptable reliability and validity, in post-operative medicine and in oncologic pain, but data in the Emergency Departments (EDs) are poor. The aim of this study is to evaluate the Emergency Nurses’ (ENs) perception about the reliability of NRS in the triage process. A questionnaire based on 11 items was designed and subsequently administered to a large number of ENs in several EDs in Northern and Central Italy. 301 questionnaires were filled out and returned. The majority declares using NRS scale to measure pain (item 2, mode = 4, mean = 3.8), and attributing priority code based on NRS valu...