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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Tag: emergency department

Improving Emergency Department Capacity Efficiency

Abstract

Objective. The demand for emergency services has risen dramatically around the world. Many Emergency Departments (EDs) have signs of low capacity efficiency (which we define as the rate at which a production facility with limited resources can convert input into output); insufficient resources (staffing, equipment, facilities), inefficient ways to use them, or both. Our purpose was to investigate how to improve ED capacity efficiency through layout planning and present some novel ideas of ED bottlenecks.

Methods. We adopted an industrial engineering perspective to one Finnish ED as a case example. In contrary to a simple case report we used more generalizable methods and demand-supply chain analysis to improve capacity efficiency.

Results. This study resulted in concrete and generalizable improvements of capacity efficiency concerning both ED premises and staffing. The former includes designing patient locations, organizing beds, improving space usage and optimizing an ED layout. The latter identified the demand for different specialties and optimal allocation of nursing staff.

Conclusion. We present a rather unique combination of ways to enhance ED functionality by using methods of industrial engineering.

Key words: capacity efficiency, emergency department, operations management, healthcare

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Stray bullet injuries in a tertiary care center

Abstract

Background. A stray bullet injury is defined as an accidental firearm injury occurring outdoors by an anonymous attacker. Stray bullet injuries are rare, but not uncommon in certain parts of the world. In Pakistan, 165 patients with stray bullet injuries were recorded between 2006 and 2010.

Objectives. In Lebanon, gunshots may occur during politicians’ speeches, funerals and after exam results are published. No studies to date have looked at the details and consequences of these gunshot injuries.

Methods. A retrospective chart review of patients presenting to an emergency department (ED) in Beirut, Lebanon, from 2010 to 2015, with clear stray bullet injuries was conducted. Variables included: demographics, injured body part, admission to hospital, number of days in hospital, length of stay in the ED, mortality, past medical history, emergency severity index, and consequences of injury including surgery.

Results. Out of 154 bullet injuries, 12 stray bullet injuries were recorded. Injuries of the lower extremity were most common, followed by the head, shoulder/thorax, abdomen/pelvis and upper extremity. Surgery was needed in 7 patients (58.3%). The median length of stay was 3.08 hours in the ED and 4.78 days in hospital. There were no recorded deaths. Consequences of each stray bullet injury are presented.

Conclusion. Stray bullet injuries are commonly reported on in news and media outlets. This is the first study in Lebanon and the region to document cases of stray bullet injuries presenting to the ED. Better laws and educational policies need to be implemented to help discourage this practice.

Key words: stray bullets, emergency department, injured body part, consequences of stray bullets, hospital admissions, severity of injury, surgical intervention, Lebanon

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Emergency department chest and abdominal computed tomography: impact on patients’ management

Abstract

Objective. The introduction of computed tomography (CT) has had a very significant impact on patient evaluation and management decisions in the Emergency Department (ED). One of the few published studies demonstrated a positive CT yield in 67% of patients admitted to hospital. The same study demonstrated that in 25% of cases, the CT examination was able to identify a pathological process unidentified by the ED team. Only one study has focused on the evaluation of the variation in patient management that each CT examination is able to achieve. The purpose of our study is to document the impact that CT has on patient diagnosis and management in the ED, employing a large patient series.

Materials and methods. The diagnostic and therapeutic impact of CT was evaluated in a consecutive series of 300 patients who were referred to the radiology department for a chest or abdominal CT examination as requested by the emergency physician.

Results. The net impact of performing a CT was a change in planned treatment in 202 cases out of 300 (67%) and proceding with the planned treatment in the remaining 98 cases (33%). The only intention to demand a CT examination was significantly bound (p=0.015, confidence interval 0.16 and 0.38) to a change in the planned treatment before CT (as it is established with Mc Nemar test).

Discussion. Our study showed that more than 67% of CT reports were able to change the course of treatment planned before CT execution and that in 56% of these cases, the execution of a CT examination was able to generate a major variation in treatment plan.

Key words: emergency department, computed tomography, chest, abdomen, clinical impact

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Safety of Blunt Spinal Injury Patient on Hospital Gurney

Abstract

Objectives. Restraint of patients on a spine board has been used in the past to prevent further spinal cord injury after rescue of patients from the scene of an accident. Removal from the spine board is a routine protocol in many hospitals once the patient has been cleared of spinal injury. However, the benefit of using a spine board, in light-weight motorcycle-related accident victims, has never been studied before.
Materials and methods. A retrospective observational study enrolled patients who had sustained motorcycle-related accidents and were brought to our emergency department (ED). Patients with a Glasgow Coma Scale score lower than 15 and those who died at the ED, or had incomplete data, were excluded. The diagnosis of spinal injury was based upon clinical evaluation and was confirmed by computed tomography, magnetic resonance imaging or X-ray reports, as interpreted by a qualified radiologist. A neurological examination was performed, according to the Standard Neurological Classification of Spinal Cord Injury, directly after arrival and again before leaving the ED.
Results. During the study period, from January 2007 to December 2010, 91 patients with spinal injuries who met the inclusion criteria, consisting of 35 male and 56 female patients with a mean age of 45.44±18.12 years, were enrolled in our study. The scores of the motor and sensory neurological exams did not show any significant change during the ED stay after being placed in a gurney without a spine board (p=0.432).
Conclusions. Removal of the spine board and placement on a hospital gurney sponge is safe in alert patients whose primary examination is completed at the ED.

Key words: motorcycle accident, spinal injury, spine board, emergency department

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Migraine due to intraparenchymal hemorrhage during a blast crisis

Abstract

Background. Hyperleukocytosis is defined as a white blood cell (WBC) count in excess of 100,000 per mm3. Hyperleukocytosis can cause leukostasis syndrome, the accumulation of leukemic blast cells within the capillary lumen, resulting in neurologic and pulmonary manifestations that can lead to intracranial haemorrhage and respiratory failure.
Objective. Identify a correct diagnostic approach, as the diagnosis of leukostasis in a patient suffering from acute leukemia with hyperleukocytosis is made only clinically. A full blood cell count and a peripheral blood smear are essential for diagnosing leukostasis.
Case report. A 19 year old girl presented to the emergency department reporting onset of headache, absence of regression of symptoms after taking painkillers (non steroidal anti inflammatory drugs (NSAIDs)), intense fatigue and absence of fever. On examination, modest hypotension and anisocoria (with reactive pupils) were evidenced. A brain computed tomography (CT) scan was performed. Several, large areas of parenchymal haemorrhage were identified. A chest and abdomen CT scan was requested. The images demonstrated the presence of splenomegaly. The laboratory findings confirmed the suspected diagnosis, with a leukocyte count equal to 980,000 units per mm3 and a platelet count of 24,000 units per mm3.
Conclusion. Given the clinical case and its evolution, no report of recent onset of headache, especially in young patients, should be underestimated.

Key words: intraparenchymal hemorrhage, hyperleukocytosis, leukostasis, leukaemia, emergency department

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