Disaster Medicine and Public Health Preparedness, 2016
Hospitals need to be fully operative during disasters. It is therefore essential to be able to ev... more Hospitals need to be fully operative during disasters. It is therefore essential to be able to evaluate hospital preparedness. However, there is no consensus of a standardized, comprehensive and reliable tool with which to measure hospital preparedness. The aim of the current study was to perform a systematic review of evaluation tools for hospital disaster preparedness. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words "crisis," "disaster," "disaster medicine," "emergency," "mass casualty," "hospital preparedness," "hospital readiness," "hospital assessment," "hospital evaluation," "hospital appraisal," "planning," "checklist," and "medical facility" were used in combination with the Boolean operators "OR" and "AND." PubMed (National Library of Medicine, Bethesda, MD), ISI Web of Science (Thomson Reuters, New York, NY), and Scopus (Elsevier, New York, NY) were searched. A total of 51,809 publications were screened. The following themes were required for relevance: logistics, planning, human resources, triage, communication, command and control, structural and nonstructural preparedness, training, evacuation, recovery after disaster, coordination, transportation, surge capacity, and safety. The results from 15 publications are presented. Fifteen articles fulfilled the criteria of relevance and considered at least 1 of the 14 predetermined themes. None of the evaluated checklists and tools included all dimensions required for an appropriate hospital preparedness evaluation. The results of the current systematic review could be used as a basis for designing an evaluation tool for hospital disaster preparedness. (Disaster Med Public Health Preparedness. 2016;page 1 of 8).
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016
Vital signs are widely used in emergency departments. Previous studies on the association between... more Vital signs are widely used in emergency departments. Previous studies on the association between vital signs and mortality in emergency departments have been restricted to selected patient populations. We aimed to study the association of vital signs and age with 1-day mortality in patients visiting the emergency department. This retrospective cohort included patients visiting the emergency department for adults at Södersjukhuset, Sweden from 4/1/2012 to 4/30/2013. Exclusion criteria were: age < 18 years, deceased upon arrival, chief complaint circulatory or respiratory arrest, key data missing and patients who were directed to a certain fast track for conditions demanding little resources. Vital sign data was collected through the Rapid Emergency Triage and Treatment System - Adult (RETTS-A). Descriptive analyses and logistic regression models were used. The main outcome measure was 1-day mortality. The 1-day mortality rate was 0.3%. 96,512 patients met the study criteria. After adjustments of differences in the other vital signs, comorbidities, gender and age the following vital signs were independently associated with 1-day mortality: oxygen saturation, systolic blood pressure, temperature, level of consciousness, respiratory rate, pulse rate and age. The highest odds ratios was observed when comparing unresponsive to alert patients (OR 31.0, CI 16.9 to 56.8), patients ≥ 80 years to <50 years (OR 35.9, CI 10.7 to 120.2) and patients with respiratory rates <8/min to 8-25/min (OR 18.1, CI 2.1 to 155.5). Most of the vital signs used in the ED are significantly associated with one-day mortality. The more the vital signs deviate from the normal range, the larger are the odds of mortality. We did not find a suitable way to adjust for the inherent influence the triage system and medical treatment has had on mortality. Most deviations of vital signs are associated with 1-day mortality. The same triage level is not associated with the same odds for death with respect to the individual vital sign. Patients that were unresponsive or had low respiratory rates or old age had the highest odds of 1-day mortality.
We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nu... more We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nucleotide polymorphisms (SNPs) in genes encoding proteins involved in blood pressure regulation, and to apply this system in a pilot study demonstrating its feasibility in the pharmacogenetics of hypertension. A panel of 74 SNPs in 25 genes involved in blood pressure regulation was selected from the SNP databases, and genotyped in DNA samples of 97 hypertensive patients. The patients had been randomized to double-blind treatment with either the angiotensin II type 1 receptor blocker irbesartan or the â 1 -adrenergic receptor blocker atenolol. Genotyping was performed using a microarray based DNA polymerase assisted 'minisequencing' single nucleotide primer extension assay with fluorescence detection. The observed genotypes were related to the blood pressure reduction using stepwise multiple regression analysis. The allele frequencies of the selected SNPs were determined in the Swedish population. The established microarray-based genotyping system was validated and allowed unequivocal multiplex genotyping of the panel of 74 SNPs in every patient. Almost 7200 SNP genotypes were generated in the study. Profiles of four or five SNP-genotypes that may be useful as predictors of blood pressure reduction after antihypertensive treatment were identified. Our results highlight the potential of microarray-based technology for SNP genotyping in pharmacogenetics. Pharmacogenetics
Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial ... more Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial fibrosis and myocyte hypertrophy seen in hypertensive left ventricular (LV) hyper-trophy through production of transforming growth factor β1 (TGF-β1); AT1-receptor antagonists reverse ...
Disaster Medicine and Public Health Preparedness, 2016
The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS... more The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS) and the Disaster Management Indicator model (DiMI), for evaluating the in-hospital management of a disaster situation through simulation exercises. Two disaster exercises, A and B, with similar scenarios were performed. Both exercises were evaluated with regard to actions, processes, and structures. After the exercises, the results were calculated and compared. In exercise A the HICS model indicated that 32% of the required positions for the immediate phase were taken under consideration with an average performance of 70%. For exercise B, the corresponding scores were 42% and 68%, respectively. According to the DiMI model, the results for exercise A were a score of 68% for management processes and 63% for management structure (staff skills). In B the results were 77% and 86%, respectively. Both models demonstrated acceptable results in relation to previous studies. More research in this area is needed to validate which of these methods best evaluates disaster preparedness based on simulation exercises or whether the methods are complementary and should therefore be used together. (Disaster Med Public Health Preparedness. 2016;page 1 of 5).
ABSTRACT Timely identification and treatment of sepsis is crucial for patient outcome. The aim of... more ABSTRACT Timely identification and treatment of sepsis is crucial for patient outcome. The aim of this study was to compare two previously unvalidated prehospital sepsis screening tools with clinical judgment by emergency medical services (EMS) personnel with respect to identification of septic patients. We carried out a retrospective cross-sectional study of 353 adult patients, transported by the EMS, with a hospital discharge International Classification of Diseases code consistent with sepsis. We analyzed EMS records for the identification of sepsis according to two screening tools and clinical judgment by EMS providers. The Robson screening tool includes temperature, heart rate, respiratory rate, altered mental status, plasma glucose, and a history suggestive of a new infection. BAS 90-30-90 refers to the vital signs: oxygen saturation, respiratory rate, and systolic blood pressure. McNemar's two related samples test was used to compare the sensitivity of the two screening tools with the sensitivity of clinical judgment. The Robson screening tool had a sensitivity of 75% (18 out of 24 patients for whom all parameters were documented, P<0.001, as compared with clinical judgment). BAS 90-30-90 had a sensitivity of 43% (76 out of 175 patients, P<0.001). EMS personnel documented suspected sepsis in 42 out of 353 (12%) patients with sepsis. The Robson screening tool had a sensitivity superior to both BAS 90-30-90 and clinical judgment. This supports our hypothesis that the implementation of a screening tool could lead to increased prehospital identification of sepsis, which may enable a more timely treatment of these patients.
Background: In 2013, Danish policy-makers on a nationwide level decided to set up a national qual... more Background: In 2013, Danish policy-makers on a nationwide level decided to set up a national quality of care database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of the study was to describe the Delphi process that contributed to the selection of quality indicators for a new national database of hospital-based emergency care in Denmark. Methods: The process comprised a literature review followed by a modified-Delphi survey process, involving a panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal to five (=agree). The Delphi process was followed by final selection by the steering group for the new database. Results: Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the initial version of the national database for hospital-based emergency care. Conclusions: The two-round modified Delphi process contributed to the selection of an initial set of nine quality indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made by the database steering group informed by the Delphi process.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016
The presentation of sepsis is varied and our hypotheses were that septic patients with non-specif... more The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC. Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar's two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis. Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00-10:40, vs. 03:56 h:minutes; IQR 2:21-7:32) and an increased in-hospital mortality (crude OR = 4.01; 95% CI, 2.19-7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95% CI, 2.12-8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6%, p < 0.001), but a lower specificity (68.3 vs. 100.0%, p < 0.001), as compared to clinical judgment. This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients. The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.
Sepsis is a serious condition which requires early treatment. We often fail to recognize sepsis p... more Sepsis is a serious condition which requires early treatment. We often fail to recognize sepsis patients in the chain of prehospital care. Knowledge of how sepsis is expressed in calls to the emergency medical communication centre (EMCC) is limited. An increased understanding could lead to earlier identification of patients with sepsis. The aim of this study was to describe the descriptions of sepsis used during communication between the caller and the emergency medical dispatcher (EMD). To achieve the aim of the study, an inductive approach of qualitative content analysis was used. In total, 29 consecutive patients, who arrived at the emergency department by ambulance and received a diagnosis of sepsis according to the International Classification of Diseases (ICD)-10, were included in the study. For each case, the corresponding emergency call recording from the EMCC was transcribed verbatim. Main categories and subcategories from the text were abstracted. From fifteen subcategorie...
Coronary heart disease is the leading cause of death in the Western world. Approximately half of ... more Coronary heart disease is the leading cause of death in the Western world. Approximately half of all the people who have their 1st heart attack and 2/3 of those with their first stroke have high blood pressure levels. Hypertension affects approximately 25% of the adult population. By treating hypertension and risk factors that contribute to cardiovascular disease both mortality and morbidity can be reduced. Many drugs have proven to be effective in treating hypertension, although the individual patient's response to antihypertensive treatment varies over a wide range and cannot be predicted with methods used today. Between 30-60% of the blood pressure variation is determined by genetic factors. Also the variation in drug response is in part heritable, which defines pharmacogenetics. This review gives a general background to pharmacogenetics and its potential usage. In addition, results from recent pharmacogenetics studies on the antihypertensive effect of the angiotensin II type 1 receptor antagonist irbesartan are presented.
Background Prehospital care, starting from the patient’s first contact with the emergency medical... more Background Prehospital care, starting from the patient’s first contact with the emergency medical call centre and including medical care provided in the ambulance, is part of the continuum of care defined as emergency medicine (EM). Sweden has a network of emergency medical call centres that are all reached by one telephone number and staffed by nurses, among other personnel. Objective This review presents a summary of the prehospital care systems currently in place in Sweden, the role of the physician and the future challenges in this evolving and important field. Results and conclusions Since 2005, the presence of registered nurses in ambulance teams has become a requirement. This proved to be a turning point in the development of advanced care in the prehospital setting in Sweden. Due to overcrowding in emergency departments, the ambulance services work to steer patients from the ambulance directly to definitive care. Although there are limited numbers of physicians in the prehos...
Background: The pre-hospital assessment non-specific complaint (NSC) often applies to patients wh... more Background: The pre-hospital assessment non-specific complaint (NSC) often applies to patients whose diagnosis does not match any other specific assessment correlating to particular symptoms or diseases, though some previous studies have found them to be related to serious underlying conditions. The aim was to identify whether the structural factors such as urgency according to the dispatch priority of the Emergency Medical Communication Centre (EMCC) or work load in the Emergency Medical Services (EMS) are predisposing factors for the assessment of NSC instead of a specific assessment. Methods: All patients with assessed condition NSCs by the EMS to Södersjukhuset during 2011 (n = 493) were compared with gender-and age-matched controls (n = 493), which were randomly drawn from all patients with specific conditions in the EMS, regarding day of week, time of day and priority set by EMCC with chi-squared tests and multivariate logistic regression models. Results: Among patients with NSCs, more were females (58 %) and the median age was 82. Almost all patients were categorized with NSCs during the daytime (8 a.m. to 9 p.m.), i.e. 450 (91 %) as compared to 373 (75 %) of those with specific conditions (p < 0.01). The risk of having an EMS dispatched as low priority by the EMCC was almost doubled among patients with NSCs compared to controls (OR 1.97, 95 % CI 1.38-2.79). Conclusions: Since patients with NSCs appear most frequently during the hours with most transportations for the EMS, i.e. 10 a.m. to 2 p.m., and the risk of having the assessment NSC was doubled if the EMCC dispatched EMS as low priority, structural factors might be predisposing factors for the assessment.
European journal of emergency medicine : official journal of the European Society for Emergency Medicine, Jan 26, 2015
The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine ... more The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine whether residents have attained the level of competence of specialists, but also to guide and facilitate residency training. The Swedish Society for Emergency Medicine has developed checklists that delineate criteria of consideration and action items for particular processes. These checklists are freely available and used to assess competence during the examination. They are also intended for use during teaching and clinical care, thus promoting alignment between clinical practice, teaching and assessment. The examination is carried out locally by residency program educators, thereby obviating travel expenses. It consists of a total of 24 stations and over 100 potential scenarios, thereby minimizing case specificity. Each station consists of a scenario based on a real case. The checklists allow for direct feedback to the examinee after each station. This model may be of interest to other...
The aim of this study was to perform a comprehensive systematic review of emergency department pe... more The aim of this study was to perform a comprehensive systematic review of emergency department performance indicators in relation to evidence. A systematic search was performed through PUBMED, EMBASE, CINAHL and COCHRANE databases with (and including synonyms of) the search words: [emergency medicine OR emergency department] AND [quality indicator(s) OR performance indicator(s) OR performance measure(s)]. Articles were included according to the inclusion/exclusion criteria using the PRISMA protocol. The level of evidence was rated according to the evidence levels by the Oxford Centre for Evidence-Based Medicine. Performance indicators were extracted and organized into five categories; outcome, process, satisfaction, equity and structural/organizational measures. Six thousand four hundred and forty articles were initially identified; 127 provided evidence for/against a minimum of one performance indicator: these were included for further study. Of the 127 articles included, 113 (92%) were primary research studies and only nine (8%) were systematic reviews. Within the 127 articles, we found evidence for 202 individual indicators. Approximately half (n=104) of all this evidence (n=202) studied process-type indicators. Only seven articles (6%) qualified for high quality (level 1b). Sixty-six articles (51%) were good retrospective quality (level 2b or better), whereas the remaining articles were either intermediate quality (25% level 3a or 3b) or poor quality (17% level 4 or 5). We found limited evidence for most emergency department performance indicators, with the majority presenting a low level of evidence. Thus, a core group of evidence-based performance indicators cannot currently be recommended on the basis of this broad review of the literature.
Australasian emergency nursing journal : AENJ, Jan 16, 2015
Men and women are equally affected by disasters, but they experience disaster in different ways. ... more Men and women are equally affected by disasters, but they experience disaster in different ways. To provide new knowledge and promote women's involvement in all phases of the disaster management, we decided to capture the perspectives and experiences of the women themselves; and to explore the conditions affecting Iranian women after recent earthquake disasters. The study was designed as a qualitative content analysis. Twenty individuals were selected by purposeful sampling and data collected by in-depth, semi-structured interviews analysed qualitatively. Three main themes were evident reflecting women's status after disaster: individual impacts of disaster, women and family, and women in the community. Participants experienced the emotional impact of loss, disorganisation of livelihood and challenges due to physical injuries. Women experienced changes in family function due to separation and conflicts which created challenges and needed to be managed after the disaster. The...
European journal of emergency medicine : official journal of the European Society for Emergency Medicine, Jan 6, 2014
Decreased general condition (DGC) is a frequent presenting complaint within the Adaptive Triage P... more Decreased general condition (DGC) is a frequent presenting complaint within the Adaptive Triage Process. DGC describes a nonspecific decline in health and well-being, and it is common among elderly patients in the emergency department (ED). The aim of this study was to compare the in-hospital mortality among patients presenting with DGC with that among patients in the corresponding triage category presenting with other complaints to an ED. The secondary aim was to describe the discharge diagnoses of patients presenting with DGC. All patients admitted to Södersjukhuset from the ED in 2008 were included. The difference in the in-hospital mortality rate was stratified for triage category at the ED, between patients with DGC (n=1182) and those with all other presenting complaints (n=20 775), and assessed with sex-adjusted and age-adjusted logistic regression models. Discharge diagnoses were assessed as the primary discharge diagnosis according to International Statistical Classification...
We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nu... more We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nucleotide polymorphisms (SNPs) in genes encoding proteins involved in blood pressure regulation, and to apply this system in a pilot study demonstrating its feasibility in the pharmacogenetics of hypertension. A panel of 74 SNPs in 25 genes involved in blood pressure regulation was selected from the SNP databases, and genotyped in DNA samples of 97 hypertensive patients. The patients had been randomized to double-blind treatment with either the angiotensin II type 1 receptor blocker irbesartan or the beta 1-adrenergic receptor blocker atenolol. Genotyping was performed using a microarray based DNA polymerase assisted 'minisequencing' single nucleotide primer extension assay with fluorescence detection. The observed genotypes were related to the blood pressure reduction using stepwise multiple regression analysis. The allele frequencies of the selected SNPs were determined in the S...
Disaster Medicine and Public Health Preparedness, 2016
Hospitals need to be fully operative during disasters. It is therefore essential to be able to ev... more Hospitals need to be fully operative during disasters. It is therefore essential to be able to evaluate hospital preparedness. However, there is no consensus of a standardized, comprehensive and reliable tool with which to measure hospital preparedness. The aim of the current study was to perform a systematic review of evaluation tools for hospital disaster preparedness. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words &quot;crisis,&quot; &quot;disaster,&quot; &quot;disaster medicine,&quot; &quot;emergency,&quot; &quot;mass casualty,&quot; &quot;hospital preparedness,&quot; &quot;hospital readiness,&quot; &quot;hospital assessment,&quot; &quot;hospital evaluation,&quot; &quot;hospital appraisal,&quot; &quot;planning,&quot; &quot;checklist,&quot; and &quot;medical facility&quot; were used in combination with the Boolean operators &quot;OR&quot; and &quot;AND.&quot; PubMed (National Library of Medicine, Bethesda, MD), ISI Web of Science (Thomson Reuters, New York, NY), and Scopus (Elsevier, New York, NY) were searched. A total of 51,809 publications were screened. The following themes were required for relevance: logistics, planning, human resources, triage, communication, command and control, structural and nonstructural preparedness, training, evacuation, recovery after disaster, coordination, transportation, surge capacity, and safety. The results from 15 publications are presented. Fifteen articles fulfilled the criteria of relevance and considered at least 1 of the 14 predetermined themes. None of the evaluated checklists and tools included all dimensions required for an appropriate hospital preparedness evaluation. The results of the current systematic review could be used as a basis for designing an evaluation tool for hospital disaster preparedness. (Disaster Med Public Health Preparedness. 2016;page 1 of 8).
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016
Vital signs are widely used in emergency departments. Previous studies on the association between... more Vital signs are widely used in emergency departments. Previous studies on the association between vital signs and mortality in emergency departments have been restricted to selected patient populations. We aimed to study the association of vital signs and age with 1-day mortality in patients visiting the emergency department. This retrospective cohort included patients visiting the emergency department for adults at Södersjukhuset, Sweden from 4/1/2012 to 4/30/2013. Exclusion criteria were: age &lt; 18 years, deceased upon arrival, chief complaint circulatory or respiratory arrest, key data missing and patients who were directed to a certain fast track for conditions demanding little resources. Vital sign data was collected through the Rapid Emergency Triage and Treatment System - Adult (RETTS-A). Descriptive analyses and logistic regression models were used. The main outcome measure was 1-day mortality. The 1-day mortality rate was 0.3%. 96,512 patients met the study criteria. After adjustments of differences in the other vital signs, comorbidities, gender and age the following vital signs were independently associated with 1-day mortality: oxygen saturation, systolic blood pressure, temperature, level of consciousness, respiratory rate, pulse rate and age. The highest odds ratios was observed when comparing unresponsive to alert patients (OR 31.0, CI 16.9 to 56.8), patients ≥ 80 years to &lt;50 years (OR 35.9, CI 10.7 to 120.2) and patients with respiratory rates &lt;8/min to 8-25/min (OR 18.1, CI 2.1 to 155.5). Most of the vital signs used in the ED are significantly associated with one-day mortality. The more the vital signs deviate from the normal range, the larger are the odds of mortality. We did not find a suitable way to adjust for the inherent influence the triage system and medical treatment has had on mortality. Most deviations of vital signs are associated with 1-day mortality. The same triage level is not associated with the same odds for death with respect to the individual vital sign. Patients that were unresponsive or had low respiratory rates or old age had the highest odds of 1-day mortality.
We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nu... more We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nucleotide polymorphisms (SNPs) in genes encoding proteins involved in blood pressure regulation, and to apply this system in a pilot study demonstrating its feasibility in the pharmacogenetics of hypertension. A panel of 74 SNPs in 25 genes involved in blood pressure regulation was selected from the SNP databases, and genotyped in DNA samples of 97 hypertensive patients. The patients had been randomized to double-blind treatment with either the angiotensin II type 1 receptor blocker irbesartan or the â 1 -adrenergic receptor blocker atenolol. Genotyping was performed using a microarray based DNA polymerase assisted 'minisequencing' single nucleotide primer extension assay with fluorescence detection. The observed genotypes were related to the blood pressure reduction using stepwise multiple regression analysis. The allele frequencies of the selected SNPs were determined in the Swedish population. The established microarray-based genotyping system was validated and allowed unequivocal multiplex genotyping of the panel of 74 SNPs in every patient. Almost 7200 SNP genotypes were generated in the study. Profiles of four or five SNP-genotypes that may be useful as predictors of blood pressure reduction after antihypertensive treatment were identified. Our results highlight the potential of microarray-based technology for SNP genotyping in pharmacogenetics. Pharmacogenetics
Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial ... more Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial fibrosis and myocyte hypertrophy seen in hypertensive left ventricular (LV) hyper-trophy through production of transforming growth factor β1 (TGF-β1); AT1-receptor antagonists reverse ...
Disaster Medicine and Public Health Preparedness, 2016
The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS... more The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS) and the Disaster Management Indicator model (DiMI), for evaluating the in-hospital management of a disaster situation through simulation exercises. Two disaster exercises, A and B, with similar scenarios were performed. Both exercises were evaluated with regard to actions, processes, and structures. After the exercises, the results were calculated and compared. In exercise A the HICS model indicated that 32% of the required positions for the immediate phase were taken under consideration with an average performance of 70%. For exercise B, the corresponding scores were 42% and 68%, respectively. According to the DiMI model, the results for exercise A were a score of 68% for management processes and 63% for management structure (staff skills). In B the results were 77% and 86%, respectively. Both models demonstrated acceptable results in relation to previous studies. More research in this area is needed to validate which of these methods best evaluates disaster preparedness based on simulation exercises or whether the methods are complementary and should therefore be used together. (Disaster Med Public Health Preparedness. 2016;page 1 of 5).
ABSTRACT Timely identification and treatment of sepsis is crucial for patient outcome. The aim of... more ABSTRACT Timely identification and treatment of sepsis is crucial for patient outcome. The aim of this study was to compare two previously unvalidated prehospital sepsis screening tools with clinical judgment by emergency medical services (EMS) personnel with respect to identification of septic patients. We carried out a retrospective cross-sectional study of 353 adult patients, transported by the EMS, with a hospital discharge International Classification of Diseases code consistent with sepsis. We analyzed EMS records for the identification of sepsis according to two screening tools and clinical judgment by EMS providers. The Robson screening tool includes temperature, heart rate, respiratory rate, altered mental status, plasma glucose, and a history suggestive of a new infection. BAS 90-30-90 refers to the vital signs: oxygen saturation, respiratory rate, and systolic blood pressure. McNemar&#39;s two related samples test was used to compare the sensitivity of the two screening tools with the sensitivity of clinical judgment. The Robson screening tool had a sensitivity of 75% (18 out of 24 patients for whom all parameters were documented, P&lt;0.001, as compared with clinical judgment). BAS 90-30-90 had a sensitivity of 43% (76 out of 175 patients, P&lt;0.001). EMS personnel documented suspected sepsis in 42 out of 353 (12%) patients with sepsis. The Robson screening tool had a sensitivity superior to both BAS 90-30-90 and clinical judgment. This supports our hypothesis that the implementation of a screening tool could lead to increased prehospital identification of sepsis, which may enable a more timely treatment of these patients.
Background: In 2013, Danish policy-makers on a nationwide level decided to set up a national qual... more Background: In 2013, Danish policy-makers on a nationwide level decided to set up a national quality of care database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of the study was to describe the Delphi process that contributed to the selection of quality indicators for a new national database of hospital-based emergency care in Denmark. Methods: The process comprised a literature review followed by a modified-Delphi survey process, involving a panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal to five (=agree). The Delphi process was followed by final selection by the steering group for the new database. Results: Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the initial version of the national database for hospital-based emergency care. Conclusions: The two-round modified Delphi process contributed to the selection of an initial set of nine quality indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made by the database steering group informed by the Delphi process.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016
The presentation of sepsis is varied and our hypotheses were that septic patients with non-specif... more The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC. Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar&#39;s two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis. Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00-10:40, vs. 03:56 h:minutes; IQR 2:21-7:32) and an increased in-hospital mortality (crude OR = 4.01; 95% CI, 2.19-7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95% CI, 2.12-8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6%, p &lt; 0.001), but a lower specificity (68.3 vs. 100.0%, p &lt; 0.001), as compared to clinical judgment. This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients. The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.
Sepsis is a serious condition which requires early treatment. We often fail to recognize sepsis p... more Sepsis is a serious condition which requires early treatment. We often fail to recognize sepsis patients in the chain of prehospital care. Knowledge of how sepsis is expressed in calls to the emergency medical communication centre (EMCC) is limited. An increased understanding could lead to earlier identification of patients with sepsis. The aim of this study was to describe the descriptions of sepsis used during communication between the caller and the emergency medical dispatcher (EMD). To achieve the aim of the study, an inductive approach of qualitative content analysis was used. In total, 29 consecutive patients, who arrived at the emergency department by ambulance and received a diagnosis of sepsis according to the International Classification of Diseases (ICD)-10, were included in the study. For each case, the corresponding emergency call recording from the EMCC was transcribed verbatim. Main categories and subcategories from the text were abstracted. From fifteen subcategorie...
Coronary heart disease is the leading cause of death in the Western world. Approximately half of ... more Coronary heart disease is the leading cause of death in the Western world. Approximately half of all the people who have their 1st heart attack and 2/3 of those with their first stroke have high blood pressure levels. Hypertension affects approximately 25% of the adult population. By treating hypertension and risk factors that contribute to cardiovascular disease both mortality and morbidity can be reduced. Many drugs have proven to be effective in treating hypertension, although the individual patient&#39;s response to antihypertensive treatment varies over a wide range and cannot be predicted with methods used today. Between 30-60% of the blood pressure variation is determined by genetic factors. Also the variation in drug response is in part heritable, which defines pharmacogenetics. This review gives a general background to pharmacogenetics and its potential usage. In addition, results from recent pharmacogenetics studies on the antihypertensive effect of the angiotensin II type 1 receptor antagonist irbesartan are presented.
Background Prehospital care, starting from the patient’s first contact with the emergency medical... more Background Prehospital care, starting from the patient’s first contact with the emergency medical call centre and including medical care provided in the ambulance, is part of the continuum of care defined as emergency medicine (EM). Sweden has a network of emergency medical call centres that are all reached by one telephone number and staffed by nurses, among other personnel. Objective This review presents a summary of the prehospital care systems currently in place in Sweden, the role of the physician and the future challenges in this evolving and important field. Results and conclusions Since 2005, the presence of registered nurses in ambulance teams has become a requirement. This proved to be a turning point in the development of advanced care in the prehospital setting in Sweden. Due to overcrowding in emergency departments, the ambulance services work to steer patients from the ambulance directly to definitive care. Although there are limited numbers of physicians in the prehos...
Background: The pre-hospital assessment non-specific complaint (NSC) often applies to patients wh... more Background: The pre-hospital assessment non-specific complaint (NSC) often applies to patients whose diagnosis does not match any other specific assessment correlating to particular symptoms or diseases, though some previous studies have found them to be related to serious underlying conditions. The aim was to identify whether the structural factors such as urgency according to the dispatch priority of the Emergency Medical Communication Centre (EMCC) or work load in the Emergency Medical Services (EMS) are predisposing factors for the assessment of NSC instead of a specific assessment. Methods: All patients with assessed condition NSCs by the EMS to Södersjukhuset during 2011 (n = 493) were compared with gender-and age-matched controls (n = 493), which were randomly drawn from all patients with specific conditions in the EMS, regarding day of week, time of day and priority set by EMCC with chi-squared tests and multivariate logistic regression models. Results: Among patients with NSCs, more were females (58 %) and the median age was 82. Almost all patients were categorized with NSCs during the daytime (8 a.m. to 9 p.m.), i.e. 450 (91 %) as compared to 373 (75 %) of those with specific conditions (p < 0.01). The risk of having an EMS dispatched as low priority by the EMCC was almost doubled among patients with NSCs compared to controls (OR 1.97, 95 % CI 1.38-2.79). Conclusions: Since patients with NSCs appear most frequently during the hours with most transportations for the EMS, i.e. 10 a.m. to 2 p.m., and the risk of having the assessment NSC was doubled if the EMCC dispatched EMS as low priority, structural factors might be predisposing factors for the assessment.
European journal of emergency medicine : official journal of the European Society for Emergency Medicine, Jan 26, 2015
The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine ... more The purpose of the Swedish specialist examination in Emergency Medicine is not only to determine whether residents have attained the level of competence of specialists, but also to guide and facilitate residency training. The Swedish Society for Emergency Medicine has developed checklists that delineate criteria of consideration and action items for particular processes. These checklists are freely available and used to assess competence during the examination. They are also intended for use during teaching and clinical care, thus promoting alignment between clinical practice, teaching and assessment. The examination is carried out locally by residency program educators, thereby obviating travel expenses. It consists of a total of 24 stations and over 100 potential scenarios, thereby minimizing case specificity. Each station consists of a scenario based on a real case. The checklists allow for direct feedback to the examinee after each station. This model may be of interest to other...
The aim of this study was to perform a comprehensive systematic review of emergency department pe... more The aim of this study was to perform a comprehensive systematic review of emergency department performance indicators in relation to evidence. A systematic search was performed through PUBMED, EMBASE, CINAHL and COCHRANE databases with (and including synonyms of) the search words: [emergency medicine OR emergency department] AND [quality indicator(s) OR performance indicator(s) OR performance measure(s)]. Articles were included according to the inclusion/exclusion criteria using the PRISMA protocol. The level of evidence was rated according to the evidence levels by the Oxford Centre for Evidence-Based Medicine. Performance indicators were extracted and organized into five categories; outcome, process, satisfaction, equity and structural/organizational measures. Six thousand four hundred and forty articles were initially identified; 127 provided evidence for/against a minimum of one performance indicator: these were included for further study. Of the 127 articles included, 113 (92%) were primary research studies and only nine (8%) were systematic reviews. Within the 127 articles, we found evidence for 202 individual indicators. Approximately half (n=104) of all this evidence (n=202) studied process-type indicators. Only seven articles (6%) qualified for high quality (level 1b). Sixty-six articles (51%) were good retrospective quality (level 2b or better), whereas the remaining articles were either intermediate quality (25% level 3a or 3b) or poor quality (17% level 4 or 5). We found limited evidence for most emergency department performance indicators, with the majority presenting a low level of evidence. Thus, a core group of evidence-based performance indicators cannot currently be recommended on the basis of this broad review of the literature.
Australasian emergency nursing journal : AENJ, Jan 16, 2015
Men and women are equally affected by disasters, but they experience disaster in different ways. ... more Men and women are equally affected by disasters, but they experience disaster in different ways. To provide new knowledge and promote women's involvement in all phases of the disaster management, we decided to capture the perspectives and experiences of the women themselves; and to explore the conditions affecting Iranian women after recent earthquake disasters. The study was designed as a qualitative content analysis. Twenty individuals were selected by purposeful sampling and data collected by in-depth, semi-structured interviews analysed qualitatively. Three main themes were evident reflecting women's status after disaster: individual impacts of disaster, women and family, and women in the community. Participants experienced the emotional impact of loss, disorganisation of livelihood and challenges due to physical injuries. Women experienced changes in family function due to separation and conflicts which created challenges and needed to be managed after the disaster. The...
European journal of emergency medicine : official journal of the European Society for Emergency Medicine, Jan 6, 2014
Decreased general condition (DGC) is a frequent presenting complaint within the Adaptive Triage P... more Decreased general condition (DGC) is a frequent presenting complaint within the Adaptive Triage Process. DGC describes a nonspecific decline in health and well-being, and it is common among elderly patients in the emergency department (ED). The aim of this study was to compare the in-hospital mortality among patients presenting with DGC with that among patients in the corresponding triage category presenting with other complaints to an ED. The secondary aim was to describe the discharge diagnoses of patients presenting with DGC. All patients admitted to Södersjukhuset from the ED in 2008 were included. The difference in the in-hospital mortality rate was stratified for triage category at the ED, between patients with DGC (n=1182) and those with all other presenting complaints (n=20 775), and assessed with sex-adjusted and age-adjusted logistic regression models. Discharge diagnoses were assessed as the primary discharge diagnosis according to International Statistical Classification...
We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nu... more We aimed to develop a microarray genotyping system for multiplex analysis of a panel of single nucleotide polymorphisms (SNPs) in genes encoding proteins involved in blood pressure regulation, and to apply this system in a pilot study demonstrating its feasibility in the pharmacogenetics of hypertension. A panel of 74 SNPs in 25 genes involved in blood pressure regulation was selected from the SNP databases, and genotyped in DNA samples of 97 hypertensive patients. The patients had been randomized to double-blind treatment with either the angiotensin II type 1 receptor blocker irbesartan or the beta 1-adrenergic receptor blocker atenolol. Genotyping was performed using a microarray based DNA polymerase assisted 'minisequencing' single nucleotide primer extension assay with fluorescence detection. The observed genotypes were related to the blood pressure reduction using stepwise multiple regression analysis. The allele frequencies of the selected SNPs were determined in the S...
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Papers by Lisa Kurland
database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of
the study was to describe the Delphi process that contributed to the selection of quality indicators for a new
national database of hospital-based emergency care in Denmark.
Methods: The process comprised a literature review followed by a modified-Delphi survey process, involving a
panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating
specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical
conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what
extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the
Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through
to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal
to five (=agree). The Delphi process was followed by final selection by the steering group for the new database.
Results: Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three
time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the
initial version of the national database for hospital-based emergency care.
Conclusions: The two-round modified Delphi process contributed to the selection of an initial set of nine quality
indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made
by the database steering group informed by the Delphi process.
database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of
the study was to describe the Delphi process that contributed to the selection of quality indicators for a new
national database of hospital-based emergency care in Denmark.
Methods: The process comprised a literature review followed by a modified-Delphi survey process, involving a
panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating
specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical
conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what
extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the
Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through
to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal
to five (=agree). The Delphi process was followed by final selection by the steering group for the new database.
Results: Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three
time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the
initial version of the national database for hospital-based emergency care.
Conclusions: The two-round modified Delphi process contributed to the selection of an initial set of nine quality
indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made
by the database steering group informed by the Delphi process.