ABSTRACTS

Global Research Highlights

� Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Medecine d’Urgence (ACMU) 2021

Editor’s note: CJEM has partnered with a small group of selected journals of international emergency medicine societies

to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of

our readership to research developments in the international emergency medicine literature, promote collaboration among

the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide,

as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health.

Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by CJEM.

Annals of Emergency Medicine

www.acep.org/annals/

Official journal of the American College of Emergency Physicians

(The print version of this article has been scheduled for March 2021)

Routine Use of a Bougie Improves First-Attempt Intubation Success in theOut-of-Hospital Setting

Andrew J. Latimer, Brenna Harrington, Catherine R. Counts, Katelyn Ruark,

Charles Maynard, Taketo Watase, Michael R. Sayre

https://doi.org/10.1016/j.annemergmed.2020.10.01

Study objective

The bougie is typically treated as a rescue device for dif-

ficult airways. We evaluate whether first-attempt success

rate during paramedic intubation in the out-of-hospital

setting changed with routine use of a bougie.

Methods

A prospective, observational, pre-post study design was

used to compare first-attempt success rate during out-of-

hospital intubation with direct laryngoscopy for patients

intubated 18 months before and 18 months after a protocol

change that directed the use of the bougie on the first

intubation attempt. We included all patients with a para-

medic-performed intubation attempt. Logistic regression

was used to examine the association between routine

bougie use and first-attempt success rate.

Results

Paramedics attempted intubation in 823 patients during the

control period and 771 during the bougie period. The first-

attempt success rate increased from 70 to 77% (difference

7.0% [95% confidence interval 3–11%]). Higher first-at-

tempt success rate was observed during the bougie period

across Cormack-Lehane grades, with rates of 91%, 60%,

27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4

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views, respectively, during the control period and 96%,

85%, 50%, and 14%, respectively, during the bougie per-

iod. Intubation during the bougie period was independently

associated with higher first-attempt success rate (adjusted

odds ratio 2.82 [95% confidence interval 1.96–4.01]).

Conclusion

Routine out-of-hospital use of the bougie during direct

laryngoscopy was associated with increased first-attempt

intubation success rate.

African journal of emergency medicine

https://www.afjem.com

The official journal of the African Federation for Emergency Medicine, the Emergency

Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the

Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association,

the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency

Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria and the

Rwanda Emergency Care Association

Building focused cardiac ultrasound capacity in a lower middle-income country:A single centre study to assess training impact

Waweru-Siika W, Barasa A, Wachira B, Nekyon D, Karau B, Juma F, Wanjiku G, Otieno H, Bloomfield GS, Sloth E

Afr J Emerg Med. 2020;10(3):136–142

https://doi.org/10.1016/j.afjem.2020.04.011

Background

In low- and middle-income countries (LMICs) where

echocardiography experts are in short supply, training non-

cardiologists to perform Focused Cardiac Ultrasound

(FoCUS) could minimise diagnostic delays in time-critical

emergencies. Despite advocacy for FoCUS training how-

ever, opportunities in LMICs are limited, and the impact of

existing curricula uncertain. The aim of this study was to

assess the impact of FoCUS training based on the Focus

Assessed Transthoracic Echocardiography (FATE) cur-

riculum. Our primary objective was to assess knowledge

gain. Secondary objectives were to evaluate novice FoCUS

image quality, assess inter-rater agreement between expert

and novice FoCUS and identify barriers to the establish-

ment of a FoCUS training programme locally.

Methods

This was a pre-post quasi-experimental study at a tertiary

hospital in Nairobi, Kenya. Twelve novices without prior

echocardiography training underwent FATE training, and

their knowledge and skills were assessed. Pre- and post-test

scores were compared using the Wilcoxon signed-rank test

to establish whether the median of the difference was dif-

ferent than zero. Inter-rater agreement between expert and

novice scans was assessed, with a Cohen’s kappa[ 0.6

indicative of good inter-rater agreement.

Results

Knowledge gain was 37.7%, with a statistically significant

difference between pre-and post-test scores (z = 2.934,

p = 0.001). Specificity of novice FoCUS was higher than

sensitivity, with substantial agreement between novice and

expert scans for most FoCUS target conditions. Overall,

65.4% of novice images were of poor quality. Post-work-

shop supervised practice was limited due to scheduling

difficulties.

Canadian Journal of Emergency Medicine (2021) 23:260–264 261

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Conclusion

Although knowledge gain is high following a brief training

in FoCUS, image quality is poor and sensitivity low

without adequate supervised practice. Substantial agree-

ment between novice and expert scans occurs even with

insufficient practice when the prevalence of pathology is

low. Supervised FoCUS practice is challenging to achieve

in a real-world setting in LMICs, undermining the effec-

tiveness of training initiatives.

Reproduced with permission

Emergency Medicine Journal

https://www.emj.bmj.com

Official Journal of the Royal College of Emergency Medicine

Oxygen therapy and inpatient mortality in COPD exacerbation

Carlos Echevarria, John Steer, James Wason, Stephen Bourke

http://dx.doi.org/10.1136/emermed-2020-210749

Background

In hospitalised patients with exacerbation of Chronic

Obstructive Pulmonary Disease, European and British

guidelines endorse oxygen target saturations of 88–92%,

with adjustment to 94–98% if carbon dioxide levels are

normal. We assessed the impact of admission oxygen sat-

uration level and baseline carbon dioxide on inpatient

mortality.

Methods

Patients were identified from the prospective Dyspnoea,

Eosinopenia, Consolidation, Acidaemia and Atrial Fibril-

lation (DECAF) derivation study (December 2008–June

2010) and the mixed methods DECAF validation study

(January 2012 to May 2014). In six UK hospitals, of 2645

patients with COPD exacerbation, 1027 patients were in

receipt of supplemental oxygen at admission. All had a

clinical history of COPD and obstructive spirometry. These

patients were subdivided into the following groups:

admission oxygen saturations of 87% or less, 88–92%, 93–

96% or 97–100%. Inpatient mortality was calculated for

each group and expressed as ORs. The DECAF score and

National Early Warning Score 2 (excluding oxygen satu-

ration) were used in binary logistic regression to adjust for

baseline risk.

Results

In patients with COPD receiving supplemental oxygen,

oxygen saturations above 92% were associated with higher

mortality and an adverse dose–response. Compared with

the 88–92% group, the adjusted risk of death (OR) in the

93–96% and 97–100% groups was 1.98 (95% CI 1.09–

3.60, p = 0.025) and 2.97 (95% CI 1.58–5.58, p = 0.001).

In the subgroup with normocapnia, the mortality signal

remained significant in both the 93–96% and 97–100%

groups.

Conclusion

Inpatient mortality was lowest in those with oxygen satu-

rations of 88–92%. Even modest elevations in oxygen

saturations above this range (93–96%) were associated

with an increased risk of death. A similar mortality trend

was seen in both patients with hypercapnia and normo-

capnia. This shows that the practice of setting different

target saturations based on carbon dioxide levels is not

justified. Treating all patients with COPD with target sat-

urations of 88–92% will simplify prescribing and should

improve outcome.

262 Canadian Journal of Emergency Medicine (2021) 23:260–264

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Emergencias

https://www.emergencias.portalsemes.org/English

Official Journal of the Spanish Society of Emergency Medicine

Factors associated with revisits by patients with SARS-CoV-2 infection dischargedfrom a hospital emergency department

Beatriz Lopez-Barbeito, Ana Garcıa-Martınez, Blanca Coll-Vinent, Arrate Placer, Carme Font,

Carmen Rosa Vargas, Carolina Sanchez, Daniela Pinango, Elisenda Gomez-Angelats,

David Curtelin, Emilio Salgado, Francisco Aya, Gemma Martınez-Nadal, Jose Ramon Alonso,

Julia Garcıa-Gozalbes, Leticia Fresco, Miguel Galicia, Milagrosa Perea, Miriam Carbo,

Nerea Iniesta, Ona Escoda, Rafael Perello, Sandra Cuerpo, Vanesa Flores, Xavier Alemany,

Oscar Miro, Ma del Mar Ortega, en representacion del Grupo de Trabajo sobre la atencion de la

COVID-19 en Urgencias (COVID19-URG)

Cited: Lopez-Barbeito B, Garcıa-Martınez A, Coll-Vinent

B, Placer A, Vargas CR, Sanchez C, et al. Factors associ-

ated with revisits by patients with SARS-CoV-2 infection

discharged from a hospital emergency department. Emer-

gencias. 2020;32:386–94.

Objective

To analyze emergency department (ED) revisits from

patients discharged with possible coronavirus disease 2019

(COVID-19).

Methods

Retrospective observational study of consecutive patients

who came to the ED over a period of 2 months and were

diagnosed with possible COVID-19. We analyzed clinical

and epidemiologic variables, treatments given in the ED,

discharge destination, need to revisit, and reasons for

revisits. Patients who did or did not revisit were compared,

and factors associated with revisits were explored.

Results

The 2378 patients included had a mean age of 57 years;

49% were women. Of the 925 patients (39%) discharged,

170 (20.5%) revisited the ED, mainly for persistence or

progression of symptoms. Sixty-six (38.8%) were hospi-

talized. Odds ratios (ORs) for the following factors showed

an association with revisits: history of rheumatologic dis-

ease (OR, 2.97; 95% CI 1.10–7.99; p = 0.03), digestive

symptoms (OR, 1.73; 95% CI 1.14–2.63; p = 0.01), res-

piratory rate over 20 breaths per minute (OR, 1.03; 95% CI

1.0–1.06; p = 0.05), and corticosteroid therapy given in the

ED (OR, 7.78; 95% CI 1.77–14.21, p = 0.01). Factors

associated with hospitalization after revisits were age over

48 years (OR, 2.57; 95% CI 1 42–4.67; p = 0.002) and

fever (OR, 4.73; 95% CI 1.99–11.27; p = 0.001).

Conclusion

Patients under the age of 48 years without comorbidity and

with normal vitals can be discharged from the ED without

fear of complications. A history of rheumatologic disease,

fever, digestive symptoms, and a respiratory rate over 20

breaths per minute, or a need for corticosteroid therapy

were independently associated with revisits. Fever and age

over 48 years were associated with a need for

hospitalization.

Canadian Journal of Emergency Medicine (2021) 23:260–264 263

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Hong Kong Journal of Emergency Medicine

https://www.hkjem.com

Official Journal of the Hong Kong College of Emergency Medicine

(First Published November 18, 2020 Research Article)

Validity and reliability of the triage scale in older people in a regional emergencydepartment in Hong Kong

Kai Yeung Cheung, Ling Pong Leung

https://journals.sagepub.com/doi/10.1177/1024907920971633

Background

Older people (C 65 years) present a unique challenge in

emergency department triage. Hong Kong’s Hospital

Authority adopts a five-level emergency department triage

system, with no special considerations for older people. We

evaluated the validity and reliability of this triage scale in

older people in a regional Hong Kong emergency

department.

Methods

In total, 295 cases stratified by triage category were ran-

domly selected for review from November 2016 to January

2017. Validity was established by comparing the real

emergency department patients’ triage category against (1)

that of an expert panel and (2) the need for life-saving

intervention. Triage notes were extracted to make case

scenarios to evaluate inter- and intra-rater reliabilities.

Emergency department nurses (n = 8) were randomly

selected and grouped into\ 5 and C 5 years emergency

department experience. All nurses independently rated all

295 scenarios, blinded to clinical outcomes.

Results

The percentage agreement between the real emergency

department patients’ triage category and the expert panel’s

assignment was 68.5%, with 16.3% and 15.3% over-triage

and under-triage, respectively. Quadratic weighting kappa

for agreement with the expert panel was 0.72 (95% confi-

dence interval 0.53–0.91). The sensitivity, specificity and

positive likelihood ratio for the need for life-saving inter-

ventions were 75.0% (95% confidence interval 47.6–

92.7%), 97.1% (95% confidence interval 94.4–98.8%) and

26.2 (95% confidence interval 12.5–54.8%), respectively.

The Fleiss kappa value for inter-rater reliability was 0.50

(95% confidence interval 0.47–0.54) for junior and senior

nurse groups, respectively.

Conclusion

The current triage scale demonstrates reasonable validity

and reliability for use in our older people. Considerations

highlighting the unique characteristics of older people

emergency department presentations are recommended.

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