Acute care addresses immediate resuscitation and early disposition to definitive care. Delay in final disposition from the emergency department (ED) affects outcomes in terms of morbidity and mortality. An audit was performed to assess the impact of protocols on red area disposition time.

An audit of red (resuscitation) area disposition time was performed among patients with compromised airway, breathing, and circulation. The red area disposition time was defined as the time from ED arrival to red area disposition. Pre-protocol data from nursing report books were reviewed for ED to operating room (OR), ED to intensive care unit (ICU), and overall disposition time between September 2007 and January 2008. Similar outcomes were documented after implementation of protocols during February to December 2008.

In the pre-protocol period, 992 red area patients were enrolled out of 10,000 ED visits. Out of which 527 (53.1%) were shifted to the OR and 222 (22.3%) to ICU. The average ED disposition time was 3.5 hours (range 2–5). Similarly, 1797 red area patients were enrolled in the post-protocol period out of 25,928. Of these, 453 (25.2%) patients were shifted to the OR, and 423 (23.7%) were shifted to the ICU. The average ED disposition time was 1.5 hours (range 10 minutes–3 hours).

Implementation of protocols improves the red area disposition time of the ED. Auditing is an important tool to address patient safety issues.

Emergency medicine (EM) is a long-awaited specialty to be established in Nepal, although it has been practiced for a long time starting with hospitals in Nepal. Currently, almost all hospital emergency departments in Nepal are run under general practitioners (GPs) as emergency consultants (emergency physicians) and medical officers work as 24-hour duty doctors.

This was a five-year observational study (2006–2010) after the Department of General Practice joined with MD in Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal.

There are no academically trained MD physicians working in Nepal according to the Nepal Medical Council's Registered Doctors, however, there are Nepalese doctors trained and working in EM in foreign countries. There is a demand of training those GPs interested in EM in a Fellowship/MPhil/MD program. There is a need for developing curriculum of EM for the Fellowship/MPhil/MD or for a different level of training collaborating with universities abroad. There is no ideal prehospital EM/emergency medical services capable of ambulance services. There must be a national code for mobilization and it must be under an umbrella of a governmental Department of GP and EM. Development of infrastructure for the EM department in every hospital in different parts of country is also a challenging task. Standards must be developed for EM and the EMS according to the need of the country. All known and unknown challenges can be addressed by coordinating with international support.

The emergency department (ED) deals with serious diseases, trauma, and terminal stage cases. The mortality pattern of cases in the ED must be assessed for future planning and development.

The aim of this study is to evaluate the pattern of the mortality cases in ED.

Retrospective mortality data were collected and analyzed during April to September 2010 from the Tribhuvan University Teaching Hospital.

There were 81 mortality records found during the study period. The mortality rate among the ED cases was 36 per 10,000 (0.36%). Sixteen (19.75%) were dead upon arrival to the ED. Among the remaining 65 mortality cases, 30 (46.2%) were male and 35 (53.8%) female. The ages ranged from 1 to 80 years; the mean age for males was 43.8 years and 55.0 years for females. The mean time duration from when the patient was bought to the ED to death was 6.7 hours. The primary causes of mortality were hypovolumic with hemorrhagic shock (10, 15.5%), aspiration pneumonitis (9, 13.8%), cardiopulmonary arrest (8, 12.4%), sepsis and septic shock (7, 10.8%), severe head injury (6, 9.3%), acute exacerbations of chronic obstructive pulmonary disease (6, 9.3%), hemorrhagic cerebrovascular accident (3, 4.7%), hepatic encephalopathy (3, 4.7%), cardiogenic shock (2, 3%), chronic renal failure (2, 3%), dyselectrolytemia (2, 3%), anaphylaxis (1, 1.5%), acute respiratory distress syndrome (1, 1.5%), meningoencepahalitis (1, 1.5%), acute myocardial infarction (1, 1.5%), OP poisoning (1, 1.5%), pulmonary edema (1, 1.5%), and severe pneumonia (1, 1.5%).

The mortality in the ED is due to the high rate of severe and serious cases that arrive at late stages of disease. It also is accounted with severe trauma cases despite vigorous treatment at the ED. The rate also is increased by “Brought Dead” cases which could be reduced with proper emergency medical services.

Timely actions can facilitate the efficacy of Emergency Medical Services (EMS) response in disaster by understanding the scale of event and shifting of traditional tasks. A simple scaling system of earthquakes/disasters by ABC is proposed: Level A treated by the local EMS. One or more Multi Casualty Incident's (MCI) in a defined geographical area that can easily be Level B hours, by reinforcement of regional and national aid coordinated by automatic autonomic response. An earthquake/disaster where the EMS and medical community can complete their task within 48 Level C - An earthquake/disaster that even joint national forces cannot eliminate within 48 hours.

Information from medical systems around the world was gathered to help develop strategies to minimize the weaknesses whilst achieving the objectives of the EMS via adapting to shifting conditions.

EMS goal is to provide treatment to those in need of urgent medical care and arrange for timely transfer of the patient to definitive care. EMS are not qualified or equipped to delay victims in the field for hours or days. However, many patients in earthquakes do not require definitive treatment or have an immediate lifethreatening.

By scaling the event by the ABC - a timely coordinated autonomic regional / national response can begin immediately. An area defined as level A will automatically back-up a level B/C area, in an event that the standard communication and activation systems collapse. Moreover, a clear shift in EMS roles will take place in a level B or C events. Available-Hours Busy-48-Hours Catastrophe-weeks Types of Levels area for delaying evacuation. Prioritizing, sorting and sending patients that require immediate attention to definitive care whilst considering availability of destination facilities and transportation resources. Patients that do not require immediate attention or cannot be saved shall await evacuation.

Developing alternative systems to deliver emergency health services during a pandemic or public health emergency is essential to preserving the operation of acute care hospitals and the overall health care infrastructure. Alternate care sites or community-based care centers which can serve as areas for primary screening and triage or short-term medical treatment can assist in diverting non-acute patients from hospital emergency departments and manage non-life threatening illnesses in a systematic and efficient manner. Additionally, if planned for correctly these facilities can also be used to decant less critical patients from inpatient wards thereby increasing the surge capacity of acute care hospitals.

A model concept of operations plan for alternate care sites to be used during pandemics and large-scale public health emergencies was developed over a 3 year period, 2007–2010. Subject matter experts were convened and best-practice methods were used to design operational plans, clinical protocols, modified standards of care, and checklists for facilities appropriate to locate such a facility. This model plan was designed to allow the mild to moderately ill patient to be managed in a non-acute care hospital or community-based care setting and then ultimately return to their homes for convalescence, following a public health emergency where regional surge capacity had been exceeded.

Over three years of interagency, comprehensive planning, training and review was conducted to create the model alternate care site/community-based care center concept of operations plan. Accomplishments and milestones included: Creating stakeholders, engaging community partners, site selection, staffing issues, detailed medical protocols and clinical pathways, functional role development, equipment and supplies, site security, media and communications plans, designing training programs and conducting drills and exercises.

The key tenets of the concept, planning, operation and demobilization of an alternate care site or community-based care center will be discussed in this session. Participants will learn what has worked based on our planning experience. Lessons learned and best-practices developed in our program will be presented to assist attendees in beginning or continuing the process of creating surge capacity in the out-of-hospital setting, by planning to operate alternate care sites in their local areas.

Emergency physicians often encounter patients who require procedural sedation and analgesia (PSA) for the treatment of acute traumatic injuries like fracture reduction, joint dislocation reduction, wound care, and pain relief. Its complications include airway or circulatory compromise. Ultrasound (US) guided peripheral nerve block is a safe alternative that utilizes minimal amounts of local anesthetic and does not require hemodynamic monitoring or prolonged post-procedure observation.

The objective of this study is to determine the feasibility and safety of ultrasonography-guided nerve blocks, performed by emergency physicians.

A prospective study involving 28 patients > 12 years of age presenting to an emergency department (ED) were recruited after informed consent. Ultrasonography-guided nerve blocks were performed by emergency physicians who underwent a minimal training of 10 supervised nerve blocks. Brachial plexus, forearm, and lower-limb nerve blocks were performed as deemed necessary. Verbal analogue scale (VAS) was used to quantify pain, before and five minutes after the procedure. The outcomes for feasibility and safety were the percentage of cases in which no further anesthesia was required, the median reduction in VAS score, median time to completion of procedure and the complication rate noted during the procedure.

All procedures were completed without additional anesthesia. The different nerve blocks performed were brachial plexus (20 cases, 71.4%), forearm (3 cases, 10.7%), femoral (2 cases, 7.1%), combined femoral and sciatic (2 cases, 7.1%) and tibial (1 case, 3.6%). Median reduction in VAS score was 7.0 points (interquartile range 6.0, 8.0; p < 0.001). The median time to completion of nerve blocks was 5 minutes per patient (interquartile range 2 minutes 25 seconds, 10 minutes 0 seconds). There were no immediate complications noted after the procedure.

Emergency physicians with minimal training can perform ultrasonography-guided nerve blocks safely, quickly and without the need for additional anesthesia in the ED.

The goal of most EMS is to provide treatment to those in need of urgent medical care, with the purpose of satisfactorily treating the problem, or arranging for timely removal of the patient to the next point of definitive care. Earthquakes are among the most destructive types of natural disasters, striking suddenly with no accurate method of prediction or warning, thereby taking a heavy toll on life, injury and property. The damage created affects all aspects of the community - transportation, telecommunication, and infrastructure and can easily overwhelm local health services, damage clinics, hospitals and render them useless.

To review the pertinent literature and to analyze the information in order to set practical guidelines for EMS work in earthquakes with a community-based approach.

Survival of casualties extricated from under the rubble depends upon early medical interventions by emergency teams on site. EMS needs to strive for: • early arrival • early qualified treatment • Earthquakes differ from other disasters, where the system is intact.: early transport and definitive care. • They present a vast number of patients • problems concerning availability of medical personnel, • accessibility to patients, means of transportation & communication.

A routine national community-based approach will strengthen the ability to provide early response in both daily and disastrous events, improving both morbidity and mortality rates. Possibly no immediate definitive care.

Trauma is one of the leading causes of morbidity and mortality across the world with traumatic brain injury (TBI) being an important cause of trauma related deaths. The aim of our study was to review the medical charts of patients who died within 24 hours of presentation to our Hospital after head injury.

We received approval from the institutional review board to conduct a retrospective review of patient charts at Acharaya Vinoba Bhave Rural Hospital, in Sawangi (M), Maharashtra (India). All patients who died within 24 hours of the presentation to the emergency department (ED) and had been diagnosed with TBI were included in the study. We collected data from 113 charts between January 2007 and December 2009.

During this three year period, 113 patients died within 24 Hours of admission to the hospital. Of these, 37% (42/113) were diagnosed with (TBI). We conducted a chart review of these 42 patients. All our patients were brought to the ED by relatives or bystanders in non-ambulance vehicles. At the time of presentation to the ED, nearly all patients were normotensive, with only one patient with hypotension The Majority of our patients had a Glasgow Coma Scale of less than 5.

Our study brings to light various deficiencies in rural India, trauma care which include immediate rescue and transportation. Although patients were provided the optimum care in the ED, however it was not associated with favorable outcome. This highlights the need of a Trauma Registry to record real-time data which will help to improve care and systems.

The role of FAST in diagnostic protocols has been adopted in most major trauma centers in well-developed countries. This procedure has become the initial diagnostic way in blunt abdominal trauma patients. However there are researches which show FAST is not reliable triage tool in patients with pelvic fracture.

To evaluate the usefulness of Focused Assessment with Sonography for Trauma in diagnostic of blunt abdominal trauma patients and to bring attention to patients with pelvic fracture who should receive additional tests for the presence of peritoneal fluid.

An analysis of high-quality evidence resources was performed, limited to the articles published since 2005 year.

99 articles were found during the search, of which 23 were accurate. 16 articles were based on original research.

Focused Assessment with Sonography for Trauma plays a key role in the investigation of blunt abdominal trauma and should be used in all emergency departments. FAST-negative patients can remain under observation except major pelvic injury patients. The evaluation of peritoneal fluid in this group has low sensitivity.

UGIB remains a common disease affecting 100 to 170 adults per year, with an associated mortality ranging from 5 to 14%, causing thereby an important burden to healthcare resources. UGIB in children is uncommon (1–2/10,000 per year) but potentially life threatening. Since various specialists (general practitioners, emergency physicians, gastroenterologists and hepatologists, pediatricians, intensivists, radiologists and surgeons) may be involved and given the absence of evidence-based medical (EBM) recommendations - for adults as well as for children - there is considerable variability in the management of UGIB. Moreover, as even RCTs on the management of UGIB in children are lacking, many treatment strategies are simply deducted from the management of adult UGIB.

To provide EBM guidelines for the care of adults and children presenting with bleeding caused by gastro-duodenal ulcer or variceal rupture.

An interuniversity interdisciplinary team of Belgian experts was launched. Statements based on the published literature up to September 2010 were collected and proposed after expert opinions reconciliation and graded accordingly to the class of evidence. The current guidelines for the management of UGIB include recommendations for the diagnosis process, general supportive care, pharmacological therapy aiming at bleeding control, specific and endoscopic treatment of acute bleeding and follow-up for both gastro-duodenal ulcers and portal hypertension induced bleeding. Specificities and differences in the approach to UGIB in children compared to adults are highlighted.

Interdisciplinary guidelines for the management of UGIB based on current standards for EBM will provide an opportunity for clinicians to improve the management of their patients. However, clinical guidelines are not mandatory tenets appropriate for all patients, but should constitute a canon or principle tailored to the individual patient. In addition, EBM might provide quality indicators for the assessment of care to bleeding patients at a local, national or international level.

Efficiency of resuscitation has been fewly assessed. The aim of our study was to compare standard manual to automatic ventilation using a new device.

5 categories of healthcare professionals were included (paramedics, nurses, respiratory therapists, senior and junior emergency physicians; n = 10 in each group) and they evaluated 2 different apparatus: manual bag valve (BVM) and automated resuscitator (EasyCPR, Weinman). The experimental bench test consisted in an artificial test lung (ASL5000, IngmarMed), simulating 3 pathological status (COPD, ALI, ASA) and connected to a resuscitation-training manikin for the interface with the mask. Recorded parameters were: tidal volume (Vt), Peak Inspiratory Pressure (PIP), Residual Volume (Vr), overall distension (Vt + Vr), respiratory rate (RR). The ergonomy of the device was assessed at the end of each sequence (1–very uneasy à 5–very easy to use).

Mean Vt reached the goal (400–600 ml) for only 26% [0, 6–45] of the cycles with BVM and 29% [0, 3–80] with the CPR. Within a same pathological status, PIP was higher with BVM (21 ± 17 cmH2O), as compared to CPR (11 ± 3 cmH2O; p < 0.001). Mean RR was 18 ± 6 C/minute with BVM and 10 ± 2 C/minute with CPR. Overall distension was significantly higher with BVM (491 ± 328 ml; up to 1750 ml), as compared to CPR (380 ± 168 ml; p < 0.001). Ergonomy of CPR was considered better for paramedics and nurses (p < 0.05).

BVM resuscitation does not allow reaching the standards in terms of Vt and RR, and may expose to overpressure (gastric distension) and thoracic overinflation. Automatic resuscitation (CPR) may standardize emergency ventilation, allowing a better fit to recommendations and an ergonomy enhancement.

Changes in gender roles, the nature of the family, marriage patterns, political shifts, the nature of work, and the increase in the number and severity of emergencies are influencing volunteering and changing it in accordance with these changes. This study in a remote rural area in the north of Thailand explores paradigms of emergency volunteering in such areas based on the concept of the multi-paradigm model of volunteering.

A sample of twenty stakeholders: leaders, village health volunteers, the director of the local administrative organization and community heads provided data during in-depth interviews. Data were analyzed using content analysis.

The results showed that the paradigms of emergency volunteering existing in the community were the functionalist paradigm and the interpreted paradigm. The functionalist paradigm relies on the belief in universal truths, thus emergency volunteering should be controlled and ordered. The community also believe that as a collective entity they achieve positive outcomes and benefits from emergency volunteering. In contrast, the interpreted paradigm relies on the belief in multiple truths. Thus emergency volunteering should be understood in terms of the individual experiences that emerge for each person from emergency volunteering. Furthermore, the community also believe that emergency volunteering should be focused on extracted cues and the process of helping emergency patients.

The conclusion of this study is that the management of emergency volunteering in the context of remote rural communities should be well ordered and be by consensus.

When implemented properly, universal helmet law increases helmet use substantially, bringing along a reduction in mortality and morbidity due to head injuries. Kerala has seen tremendous success in regards to various indicators for health within India. But when it comes to wearing helmets, the state lags behind others with reported rates as less as 27%.

A cross-sectional survey of 300 two-wheel drivers in Thiruvananthapuram City was preformed, which looked into helmet wearing patterns, their determinants, and the risk perception among the respondents. Further, a content analysis of newspaper reports pertaining to helmet legislation from the Thiruvananthapuram edition of two leading newspapers was performed. The reports included were from the periods of July 2003 to June 2005 and July 2008 to June 2010. Lastly, in-depth interviews were conducted with informants from among the key stakeholders in helmet policy of the state.

The study found 36.8% of the respondents wear a helmet. A scale to measure risk perception was developed for the purpose of this study. The four-item scale has been found to have internal consistency with a Cronbach alpha value of 0.74. The risk perception measured by using this scale has significant relation with helmet-wearing behavior. The content analysis helped in deriving a historical perspective of the policy along with the themes of reporting. The informant interviews provided expert opinions, problem identification, and specific recommendations.

The practice of wearing a helmet is low, and people with lower risk perception have greater tendency not to wear helmets. Other findings also show that there are gaps in policy and lack of visionary leadership as far as the policy toward helmet legislation and its implementation.

Handwashing has been shown to be the most effective means of reducing cross infection in the healthcare environment. However, staff compliance remains low in the real setting.

A prospective study was carried out over one month period in one cubicle of neurosurgery intensive care unit (ICU). A surveillance camera which was previously installed and functioning was focused on a cubicle of three patients, and recordings of the previous 24 hours were reviewed every day for 15 days. The number of incidents in which handwashing was required but not performed was recorded. An incident was defined as any one of the following: (1) handwashing not performed by healthcare workers; (2) touching different patients without handwashing; (3) using the same gloves for different patients and for different procedures; (4) not performing handwashing after finishing the procedures. Following this 15-day period, all staff were verbally instructed during every shift that they were under surveillance for the next 15 days. Camera recordings of the previous 24 hours were similarly reviewed every day for these 15 days and incidents recorded.

In the first 15-days period, there was a total of 480 incidents when handwashing was not performed. Of the incidents, 83%(n = 401) occurred during the night shift, especially during the early morning hours. In the subsequent 15 days when the staff were informed that they were under camera surveillance, the total number of events when handwashing was not done was 140. The difference between the two periods was statistically significant(p < 0.01 > .

Handwashing is practiced poorly in this ICU. As the maximum number of incidents occurred during the night shift, poor motivation may be one of the factors for this behavior. This study shows that camera surveillance plays a major role in changing the staff behavior and may improve compliance for handwashing.

To investigate the association of cardiac Risk factors and the risk of Acute myocardial infarction, in ED patients with non-diagnostic ECG. Methods:

474 patients were enrolled,150 had non diagnostic ECG In this study HTN with p-value = 0/012 (> 0/05), HIP with p-value = 0/0001 (> 0/001), FH with p-value = 0/001(> 0/01) was significantly more prevalent in those who ruled in for AMI.

In the past studies in patients with non-diagnostic ECG only hypertension Was significantly more prevalent in those who ruled in for AMI and cardiac risk factors have limited clinical value in diagnosing of AMI in ED patients. In this study HLP, HTN, FH was significantly more prevalent in those who ruled in for AMI An observational study is conducted in an educational hospital in Shahid Beheshti university during a period of two years. In this study, patients with symptoms suggestive of AMI including. chest pain, Dyspnea, palpitation, syncope, cerebrovascular accident, nausea, vomiting, vertigo, loss of consciousness were enrolled. Demographic, historical feature and risk factors, such as age, sex, diabetes, hypertension, hyper lipidemia, renal failure, positive family history of CAD, smoking, substance abuse, Alcohol use in the past 24 hours, cocaine use in the past 48 h were recorded. Nondiagnost ECG including these categories: Normal, non specific, early Repolarization, abnormal without signs of ischemia such as old bundle branch block, LVH, … A final diagnosis of Acute myocardial infarction was determined by CK - MB and Troponin - 1.

Information and communication technology (ICT).

ICT are introduced into organizations with the goals of managing resources, increasing efficiency and work productivity and reducing workload. In the context of developing countries, these goals are accentuated given the existing conditions. The aim of this study was to identify hospital institutional capacity indicators to provide recommendations to an emergency management database system operating in the Western Cape province of South Africa as http://hospitalbedbureau.co.za/.

A two round modified Expert Delphi study was conducted by email. A panel of 16 experts drawn from the fields of emergency medicine, critical care, trauma surgery and disaster medicine were consulted. Participants were initially asked to propose hospital institutional capacity indicators that warranted inclusion in the emergency management database system currently operating in Cape Town, South Africa. In the second round these proposals were collated and scored using a 7 point Likert scale. Areas that did not reach consensus in the Delphi study will be presented as synopsis statements for discussion at the Emergency Medicine Symposium hosted by the department of Accident and Emergency Western Cape.

Round 1 comprised 237 statements. Consensus was defined a priori to be > 80%. A total of 52 of 237 statements had reached consensus upon completion of the Delphi study. This represented 21.9% of the total number of statements. Of these 20 reached consensus at > 90% and 32 reached consensus at > 80%.

The use of a Delphi study achieved consensus in aspects of hospital institutional capacity that can be translated into practical recommendations for implementation by the local emergency management database system. Additionally, areas of non-consensus have been identified where further work is required.

With the current need for effective trauma center utilization, understanding how current trauma triage criteria may promote overtriage will enable both field and hospital teams to provide the most appropriate patient care. It is hypothesized that current Southwest Texas trauma criteria promote overtriage by prehospital emergency medical services (EMS) of patients in favor of a Level 1 trauma facility when compared to physician assessment and Injury Severity Score (ISS).

This prospective, observational study at a Southwest Texas military Level 1 trauma center compared adult trauma patients' prehospital status noted by EMS personnel with the triage criteria documented by the treating emergency physician. The patients were divided into four groups: Prehospital Criteria Met or Not Met; Arrival Criteria Met or Not Met. Each patient's ISS and mechanism of injury were also collected and compared to initial assessment for predictive value. Descriptive statistics were used.

The study enrolled 278 adult trauma patients. EMS reported Level 1 trauma status similar to physician assessment (60.1% vs. 59.7%, respectively). The rates patients met Level 1 trauma status corresponded with trauma severity when compared to the ISS. Assessment between EMS and physicians for ISSs were similar among the four groups. Comparisons using multivariate analysis of the four groups found similar ISSs, except for the Prehospital Criteria Met/Arrival Criteria Not Met group. Seventy-five percent of these patients were assigned an ISS in the Minor (ISS < 9) category (p = 0.013).

Trauma triage criteria assessment skills were similar between EMS personnel and emergency physicians except for identifying minor trauma patients. While the criteria generally led to overtriage, EMS crews appear to overtriage minor trauma patients at a much higher rate.

On 12 January 2010 Port-au-Prince, Haiti was struck by a 7.0 Mw earthquake that devastated the city and destroyed much of the Haiti University and Educational Hospital. In the following weeks, a tent hospital was erected at the site and hundreds of patients were seen daily by expatriate healthcare volunteers. The high volumes of patients, disorganized hospital grounds, and high levels of stress among patients led to issues of crowd control.

To improve security a new triage system was designed and implemented based on current emergency medicine models. This design addressed patient flow, triage, environmental conditions, and differentiation of emergency services. The results of this system were a streamlined triage system as well as improved safety.

During the chaos following the Haiti earthquake, a triage design was implemented at the HUEH that lead to improved Emergency Department patient flow and hospital safety.