Elderly in emergency -

Psychosocial support is essential to prevent mental health disorders in the elders subjected to trauma in emergencies that induces to isolation as well as risks or vulnerability for them and their environment. Financial crisis, natural disasters, attacks, poverty, violence and loneliness in the social environment turn threatening for them. Reality becomes hard and produces disorganization in mental health.

Elder people who have gone through one or more of the following situations are the ones who are prone to develop intense or immediate character disorder. With strategies that increase the existing psychosocial protection factors stress at different intervention levels is lowered. Those who have gone through one or more violent experiences are the ones who are prone to develop intense or immediate character disorder. Cultural transferring (between adults and between adults and children) and mutual help between adults and children is held.

Cognitive processing factors associated to each individual's anxiety: stress, depression, loneliness, panic attacks etc. Some techniques have been developed to understand emotions and learn how to manage them: songs, classic tales, puppets, advertisements and anagrams, Kessen cards, etc. All the material and the results were evaluated with clinic tests and professional help.

Additionally, a good cultural understanding of the situation and the adult's feelings are needed in order to provide assistance. The one providing help as well as the one receiving bio-psychosocial help are both part of the link created to overcome the impact of violence, committed to build bridges in the adversity. To prevent post-traumatic stress they are trained in facing disturbing anxiety when facing catastrophes produced by nature or men.

Advancing age and co-morbid illness result in loss of the ability to perform activities for daily living (ADLs), and are important determinants of loss of independence and autonomy among older persons. Acute illness reduces the functional status of previously healthy older persons.The aim of the current study was to determine the change in ADLs due to acute destabilization in old age one month following discharge.

Older subjects admitted to the General Medical Wards from the emergency services of the All India Institute of Medical Sciences were included between August and February 2008. The Barthel index of ADL was assessed in a longitudinal design at the time of admission and one month post discharge. The values of the indices were compared using paired samples t-test.

Of 108 subjects who presented to Emergency Geriatric Services at the hospital, 11 were excluded due to incomplete records, inability to trace on follow-up, incorrect telephone numbers, or had since died. Advancing age did not show a significant correlation with pre-morbid ADL score (r = −0.040; p = 0.749) or post-morbidity ADL score (r = −0.65; p = 0.636). A 45% decline in ADL score was noted one month following discharge after acute illness in older subjects (pre-ADL = 15.85; post-ADL = 8.78).

Older subjects are at a higher risk of poor functional outcome because they are less likely to recover function lost before admission and more likely to develop new functional deficits during hospitalization and after discharge.

Immediate resuscitation and early disposition to definitive care improves outcomes. Homeless patients are neglected in emergency department (ED). The duration of ED stay and profile of injury of homeless patients at a Level-1 Trauma center were measured.

The study was performed from October 2008 to September 2009. Homeless patients were defined as patients who had no attendant and did not have any shelter. Duration of ED stay was noted from the ED arrival time to entry time at the definitive care (intensive care unit/ward). Clinical and demographic details were recorded. Subjects who had: (1) an attendant; (2) were discharged from the ED; or (3) expired in the ED were excluded.

Forty-one homeless patients were admitted. The mode of injury was road traffic crash in 73.2%; assault in 7.3%; fall from height in 7.3%; and in 12.2%, the mode of injury unknown. The average Injury Severity Score (ISS) was 6.76, with a maximum of 34 and minimum of 1. A total of 24 subjects (59%) had a Glasgow Coma Scale (GCS) score of ≤ 8 (severe head injury), 10 patients (24%) had GCS score 9–12 (moderate head injury), and seven subjects (17%) had GCS score 13–15 (minor head injury). Breath alcohol test was positive in 13%. The average duration of ED stay was 35 (3–173) hours in the homeless group and 12 (0.5–18) hours for patients with an attendant. Twenty-one subjects were admitted to neurosurgery (51.2%) with an average ED stay of 22.4 hours, five to surgery (12.20%) with average ED stay of 56.6 hours, and 15 to orthopedics (36.6%) with average ED stay of 45.3 hours.

The emergency department stay of homeless patients was 35 hours. Orthopedic trauma subjects had a prolonged disposal time. This addresses serious patient safety concerns and immediate remedial measures.

In the US, a system has been developed to provide disaster sheltering for persons with special needs in what are now termed alternate care sites (ACS). As in many other developed countries, as the population ages, the rates of people with chronic diseases that require complex health care management in the home setting has increased. The aim of this study was to identify the key chronic diseases, conditions, and therapies that should be planned for in ACS operations.

A convenience sample (n = 402) of senior citizens (≥ 65) who resided in Honolulu, Hawaii were interviewed and completed a 15-item survey that asked about demographics, existing health conditions, activities of daily living abilities (ADL), and requirements for ongoing care.

The mean age was 68 years; 56% were female. The most common health issues included: hypertension (53.4%), heart disease (24.6%), diabetes mellitus (23.3%), and asthma (15.1%); while 11% (n = 47) reported they required daily physical assistance ADLs, including: getting up from a chair (15.1%), walking (8.1%), taking medications (8.1%), dressing (5.2%), and toileting (4.2%). Of these 47 people, most (81%) had someone who would help them in a disaster shelter, while nine (19% of the total who required assistance) had no one to help them. On average, of the respondents who reported they took medication daily, 14% had less than a seven-day supply of medication for their chronic disease.

As the population ages, the burden of chronic disease in the population increases. During a disaster with large numbers of displaced persons, accommodations for such persons must be accounted for in order to prevent a second disaster related to de-compensation of those with chronic health problems in the ACS shelter. Understanding the population needs beforehand can mitigate the effects of displacement on this population.

Disaster drills have been performed officially for disaster medical preparedness by wide regional emergency medical centers in Korea. Government evaluates these disaster drills every year, but this evaluation is performed based on administrative aspect not disaster medical aspect. Also there are insufficient number of research on disaster drill not on disaster itself, especially national level. So these disaster medical drills were analyzed and reevaluated.

Disaster drills performed by wide regional emergency medical centers in Korea were evaluated and analyzed from August 2006 to July 2008. Disaster drill planning, performance, kinds of disaster drill, contents of drill and resources of drill were collected and analyzed in medical aspect based on the disaster drill report and additional compensation of incomplete data by direct contact with the participating institutions. The appropriateness and evaluation results referred to the guideline of National Emergency Medical Center of Korea.

All the wild regional emergency medical centers had their own disaster drill planning and resource application planning for drills and real disasters. Most of disaster drill planning were appropriate, but disaster facility was the weakest point in the planning. Types of disasters in disaster drills were fire and structural collapse(44.4%), special disaster(13.7%), natural disaster(1.7%). Average duration of disaster drills were 6.12 hours and 1.26 days. Real field drill rate was 80.3%. Sixty five percent of drills were connected to multiple institutions or organizations other than hospitals. Number of participating persons from wide regional emergency medical centers were 21 on average.

Medical situation on disaster drills is that there are various levels and kinds of disaster drills done by wide regional emergency medical centers, so the quality and quantity should be enforced in low level centers. It is recommended that international situation or database can be extracted based on this research.

During the past four years large scale biological exercises took place in several districts of the state of Israel. The drills included hospitals, Health Maintenance Organizations (HMOs), Emergency Medical Services (EMS), public health district offices and interface agencies such as Israel Defense Forces (IDF) Home Front Command (HFC).

On January 2010 a comprehensive biological exercise was conducted in Tel Aviv. Tel Aviv Sourasky Medical Center (TASMC) together with the agencies mentioned above practiced the hospital competing with Exceptional Biological Event. New elements, which had never been inspected before, were evaluated in this drill:

• • Activating of a triage point at the hospital gate.

• • Opening a special registration point.

• • Staff protection from biological agents.

• • Activating a separate Emergency Department (ED) for bio- threat.

• • Detection and Containment ward.

• • Protected elevators and passageways

• • Interface agencies in and out the hospital.

Designated physicians, nurses and paramedical team, that practiced other events in the past, needed to be trained and practiced in order to be ready for a biological event. Wards that usually did not participate in such drills, needed to take part in this particular drill, while the routine work continued. This paper presents the hospital preparation for the drill, the methodology of training and preparedness, as well as the outcome of the drill.

According to the Belgian Hospital Disaster Planning Act, all hospitals are required to have written disaster plans and to routinely conduct annual disaster drills. In 2010, three neighboring hospitals organized independently from each other an evacuation exercise of a critical care department (CCD): two university hospitals of a Dialysis Center and a One-day Surgery Clinic respectively and the military hospital of a Burn Unit.

To compare these CCD's evacuation plans and drills and the overall hospital emergency incident response and command system.

Conducting an evacuation exercise in a CCD, moving vulnerable highly dependent people towards an alternative shelter site is challenging, causing an important burden to ongoing medical specialist care, working staff and critical infrastructure. In all three CCD, it was decided to conduct a simulated evacuation exercise following an internal fire, thereby deploying fashioned simulated patients and visitors but bringing into action the regular attending medical, nursing and logistic staff. In each hospital a multidisciplinary design team was launched, consisting of the hospitals disaster preparedness coordinator, the EMS-staff, external emergency incident management and operational engineering experts. The appointed objectives for evaluation were the knowledge of the regular evacuation drills, especially the clearance of an intensive care or an operating room; access to evacuation routes; visibility of safety guidelines; need of specific evacuation equipment for the movement of patients; mission and tasks of the hospital's first response team and the medical incident manager; communication and information flow and the establishment of the hospital's coordination committee.

1. Simulated hospital evacuation exercises increased the hospital emergency preparedness, awareness and response to disasters within the hospital, in particular in a CCD, otherwise difficult to assess. 2. All three CCD experienced the same challenges and identified similar flaws. 3. A hospital disaster exercise manual might be of valuable help.

Modern emergencies and disasters are progressively changing from relatively simple, predictable events controllable with standard management solutions to complex critical situations for which managers and first responders require innovative and affordable tools.

The European Project SICMA (Simulation of Crisis Management Activities) provides a modeling of the behavior of the entire Health Service System during field emergency operations, as well as the rules it operates by. Use of simulation technologies offers a significant improvement on current management activities allowing decision makers to confront several organizational alternatives not only with static situations but with evolving scenarios.

SICMA simulates main structural and behavioral elements of maxi emergency and mass casualties, from individual casualties and evolution of their health status, activity of the police force and fire brigade on the accident site, crowd dynamics, sanitary personnel expertise, to ambulance and helicopter transportation depending on traffic and weather conditions. The system also simulates rescue doctrines (i.e. “Casualty Clearing Station” or “Scoop and run”), transportation priorities according to color codes, doctrines for assignment of new casualty to neighboring hospitals, hospital resources and involvement, final clinical outcome of individual casualties. Patient health status and physiological reserve of single casualty is based on the ABCD ATLS system, considering with a simple algorithm both level of damage and rate of worsening in time.

Utilizing this simulation system, managers who predispose organizational and logistic procedures may modify the main elements in order to identify the optimal resource allocation and the best procedures to save the most human lives.

The European Project SICMA (Simulation of Crisis Management Activities) provides a modeling of the behavior of the entire Health Service System during field emergency operations, as well as the rules it operates by. The first step toward chain procedure modelling in the management of major emergencies is the representation of a traumatized patient whose health status can be followed in time during simulation. Since management of the trauma patient follows criteria of stabilization of main physiological functions, a trauma patient model was developed based on fundamental pathophysiological functions independently of specific lesion characterization. Methods: Each patient's health status was modelled according to 5 parameters (ATLS): A(airway), B(breathing), C(circulatory), D(disability), E(Exposure). Patient samples are extracted from a 10.000.000 patient database, generated by considering real anatomical lesions compatible with type and severity of considered scenarios (explosion, building collapse, fire, gunfight). Simulated lesion characteristics were then converted to pathophysiological parameters. Each physiological compensation parameter was represented by: (1) baseline value expressed as percentage of altered function; (2) function reduction rate over time, obtained by a mathematical approximation of clinical worsening. From level of function, rate of worsening and function-specific death thresholds, estimated time-to-death according to sustained damage is computed.

This model allows simulation of evolution of patient health status both in absence of medical care, but also under therapy, in terms of immediate increment of each single parameter (“temporary” treatment), and of reduction or zeroing of parameter dec14rement rate (“definitive” treatment).

This model, based on evaluation of physiological parameters, presents an advantage over the consideration of single lesions, because simulating logical procedures that guide treatment choice in real situations can provide a more accurate assessment of casualities for those actors assigned to management of major emergencies.

The ultimate goal of medical disaster management must be to predictably orchestrate transition from “standard of care” to “sufficiency of care” using evidence-based methods. However, neither descriptive reports of disaster responses nor epidemiological studies investigating disaster risk factors have been able to provide validated outcome measures as to what constitutes a “good” disaster response. Moreover, it either has been considered impossible, ethically inappropriate, or both, to identify experimental and control groups essential for hypothesis testing for the conduct of scientific randomized controlled clinical trials.

The aim of this study was to identify a number of performance and outcome indicators and define optimal disaster response and management decision-making for various disaster scenarios using simulation optimization.

A system model of medical disaster management was designed, and victim models and performance and outcome indicators were developed. Various mass-casualty and large-scale disaster scenarios were developed, including: (1) a hospital emergency incident/disaster; (2) a CBRNE incident; (3) an airplane crash and airport disaster; (4) a mass gathering; and (5) a military battlefield mass casualty. Using “Discrete Event Driven Simulation”, multiple replications were made for different decision-making modalities, different resource allocations, and different disaster response procedures. Statistical analysis and optimization techniques were applied to achieve the best available setting of parameters of the simulation model. In such a way, the “Medical Disaster Management Simulator” runs the “missing experimental studies” in a simplified artificial simulated disaster environment.

Simulation optimization is an adequate tool for judging and evaluating the effectiveness and adequacy of health and relief services provided during disaster medical response. Evidence-based recommendations and codes of best practice were formulated for optimal medical disaster and military battlefield management in different large-scale event scenarios as well as for teaching, training, and research in medical disaster management.

Associated with hospital evacuation is the need to track multiple patient evacuees from point of origination to final hospital reception. Patient tracking, a component of the hospital emergency operations plan, is vital to patient care; family association, resource management, financial reimbursement, risk management, and repatriation. Tracking strategies and plans can include a variety of vendors, hardware, software, and coordination issues. Hospital evacuee tracking plans and platforms exist at multiple jurisdictional levels but may not be interoperable.

Three patient tracking platforms representing a local, state and federal application were used during a multi-hospital evacuation exercise, initiated in New Orleans, Louisiana, May 2010. Simulated patients were flown and tracked to multiple patient reception centers in the southern United States, including the Federal Coordinating Center in Shreveport, Louisiana, and receiving National Disaster Medical System hospitals. This review summarizes tracking operations, patient data characteristics captured and interoperability at the Shreveport reception location.

7 New Orleans hospitals entered 51 patients for evacuation into Louisiana's web-based, At-Risk-Registry (ARR) database including 8 patient identifiers each. ARR data was shared with federal and Louisiana Region 7 patient evacuee receivers for flight manifest construction and reception planning. 34 ARR evacuee patients were indicated for the Shreveport, Louisiana, reception site. 34 patients with 6 identifying characteristics were entered from ARR into EMTrack, the local patient tracking system. A C130 arrived with a TRAC2ES manifest of 20 simulated patients with 6 patient data characteristics. The local tracking system was reconfigured for the hardcopy manifest; simulated patients were received at the airport; transported and received at local hospitals.

Tracking system interoperability may be challenged by tracking technologies, jurisdictional requirements and degree of implementation at the local, state and federal level. Tracking should be standardized based on national recommendations with local systems remaining flexible for just-in-time requirements.

Out-of-hospital cardiopulmonary arrest (OHA) is an international health issue. There is an urgent need to better understand the key factors that affect OHA survival. Epidemiological surveillance is the first step towards scientific understanding of the problem. This study looks at the profiles of patients who suffered an OHA.

In this retrospective study, the medical records of all patients who died upon arrival at Tan Tock Seng Hospital, Emergency Department (TTSH ED) between 1st January 2009 and 31st December 2009 were reviewed. The outcomes include patient demographics, pre-hospital management and the cause of death.

Within the study period, there were a total of 275 OHA, 5 (1.8%) traumatic and 270 (98.2%) non-traumatic cases. Emergency Medical Service (EMS) conveyed 247 (91.5%) of OHA and 23 (8.5%) arrived by self-transport. The incidence of non-traumatic OHA was 14 per 10,000 ED attendees, predominantly male (72.2%). Male were significantly younger than female (63 vs 70 years, p = 0.002). The commonest initial cardiac arrhythmia recorded on scene by paramedics was asystole (54.1%), pulseless electrical activity (34.8%) and ventricular fibrillation (11.1%). One hundred sixty-one (59.6%) patients collapsed during the day (0600 – 1759 hours). Patients found in ventricular fibrillation on scene peaked in the morning (1020hours). All OHA were started on cardiopulmonary resuscitation, intubated with laryngeal airway mask, given intravenous adrenaline, and all ventricular fibrillation was electrically defibrillated en-route by the paramedics. Despite continued resuscitative efforts in the ED, all remained in asystole. The State Coroner reviewed 266 (96.7%) OHAs, of which, 96 (36%) were subjected to post mortem. Among patients with asystole at scene, acute coronary syndrome (55.2%), hypertensive heart disease (13%) and bronchopneumonia (5.2%) were the three commonest cause of death. The commonest cause of death for ventricular fibrillation at scene was acute coronary syndrome (76.7%), of which 10 (43.5%) had no pre-existing medical conditions.

In our study population, majority of patients had asystole as their presenting arrhythmia at scene. OHA with ventricular fibrillation demonstrated significant circadian differences and the underlying cause of death was acute coronary syndrome. This knowledge will allow EMS to devise future strategies that have the greatest potential to improve survival outcomes.

To compare resuscitation outcomes before and after switching from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR in a multi-center Emergency Departments (ED) trial.

This is a phased, prospective cohort evaluation with intention-to-treat analysis of adults with non-traumatic cardiac arrest. The intervention is change in the system from manual CPR to LDB-CPR at two Urban EDs. The main outcome measure is survival to hospital discharge, with secondary outcome measures of return of spontaneous circulation (ROSC), survival to hospital admission and neurological outcome at discharge.

A total of 1,011 patients were included in the study, with 459 in the manual CPR phase (January 01, 2004, to August 24, 2007) and 552 patients in the LDB-CPR phase (August 16, 2007, to December 31, 2009). In the LDB phase, the LDB device was applied in 454 patients (82.3%). Patients in the manual CPR and LDB-CPR phases were comparable for mean age, gender and ethnicity. Rates for ROSC were comparable with LDB-CPR (manual 22.4% vs. LDB 35.3%; adjusted odds ratio [OR], 1.07; 95% confidence interval [CI], 0.63-1.83). Survival to hospital admission was increased, Manual 14.2% vs. LDB 19.7%; adjusted OR, 2.50; 95% CI, 1.05-6.00. Survival to hospital discharge was increased Manual 1.3% vs. LDB 3.3%; adjusted OR, 3.99; 95% CI, 1.06-15.02. The number of survivors with Cerebral Performance Category 1 (good) (Manual 1 vs. LDB 12, p < 0.01) and Overall Performance Category 1 (good) (Manual 1 vs. LDB 10, p < 0.01) was also increased. The Number Needed to Treat (NNT) for 1 survivor was 52 (95% CI, 26-1000).

A resuscitation strategy using LDB-CPR in an ED environment was associated with improved survival to admission and discharge in adults with non-traumatic cardiac arrest.

Cardiopulmonary resuscitation (CPR) guidelines throughout the world stress the importance of high quality chest compressions soon after cardiac arrest as the most significant factor in determining survival. Little evidence exists, internationally, documenting the quality of compressions provided by healthcare providers. In this study investigators sought to determine the quality of chest compressions delivered by rescuers. It was hypothesized that greater variably in compression quality exists between rescuers than variability in individual rescuers over time.

In this observational pilot study, basic life support (BLS) providers from prehospital and in-hospital settings were invited to participate in the investigation. Ten minutes of continuous chest compressions were recorded on the Resusci Anne and the Laerdal PC Skillreporting System. An adequate compression was defined as a compression with depth > 38mm, full chest recoil, and correct hand position. The Quality Compression Index (QCI) was developed to factor rate into the characteristics of an adequate compression. QCI is a scaled performance index calculated every 30 seconds.

Providers came from a variety of clinical backgrounds, aged 35.5 ± 11.0 years. Of the 103 total participants, 94 (91.3%) completed 10 minutes of compressions. The most significant degradation in the quality of compressions occurred within the first two minutes. There was greater variability between different rescuers than the variability over time. Mean Square Error (MSE) due to subjects was comparatively greater than the MSE due to time (63.2 vs. 7.68). Performance of CPR, male sex, < 45 years of age, and prehospital background, correlated with higher quality. Time since last BLS certification and the number of times a rescuer completed a BLS class did not correlate with the quality.

Greater variability in the quality of compressions exists between different rescuers than a rescuer over time. Some participants were not able to deliver ideal compressions from the start, when the effects of fatigue were minimal.

Golden time of thrombolysis therapy in acute ischemic stroke is only three hours. Emergency medical services transport and hospital prenotification were not been strengthened in Taiwan.

In order to elevate the medical quality of acute ischemic stroke, we developed a Quality Control Circle (QCC) focused on a comprehensive thrombolysis service for patients with acute ischemic stroke administered pre-hospital and in an emergency department.

QCC activities contained early recognition of acute stroke by EMT, hospital prenotification, early emergency management, activate the stroke team, shorten the time to CT scan and report, and early thromobolytic therapy. There were three policy groups via quality method analysis which these methods aimed to improve the efficiency and quality of management process focused on acute ischemic stroke.

Group 1: After the implementation of QCC, the number of times of pre-hospital notification was six in Mar. 2010, achieve the expected standard. Group 2: Responses were received from 160 people for the pretest and 145 people for the posttest. In the pretest and posttest analysis, significant improvement in the attitudes of the physician group (p < 0.001) and general behavior (p < 0.001) were disclosed. The case-based educational module of acute stroke was better than the traditional oral lecture especially in the nursing group (p < 0.001). Group 3: The rate of administering thrombolytic therapy/total ischemic stroke increased from 3.1% to 10.5 % (from Mar to Apr, 2010) after running the organized service. These activities reached the goal of expected standard (5%). All above groups were set up into standardization. The thrombolytic rate in effect maintainence was still around 5% eight months later.

Setting up and running a organized thrombolysis service for patients with acute ischemic stroke prehospital and in the emergency department can be a good method to increase the rate of administration of thrombolytic therapy.

To report a rare case of Acute Myocardial Infarction (AMI) along with Upper Gastrointestinal bleeding (UGIB).

A 58 year old male with history of black coloured stools was admitted in ER for chest pain and coffee ground emesis. ECG showed an acute inferior wall MI. After doing the necessary interventions, patient was inserted with a nasogastric tube and started on medications in the Emergency for UGIB followed by immediate endoscopy. Endoscopy confirmed presence of multiple superficial Ulcers in the stomach along with Esophagitis.

We support Esophagogastroduodenoscopy (EGD) prior to cardiac catheterisation in patients with AMI associated with overt Upper GI Bleed. This results in fewer complications as compared with direct catheterization

Global warming is predicted to increase the number and severity of extreme weather events. (IPCC 2007) But we can lessen the effects of these disasters. “Critically important will be factors that directly shape the health of populations such as education, health care, public health prevention and infrastructure.” (IPCC 2007) A comprehensive approach to disaster risk reduction (DRR) has been proposed for climate change adaptation. (Thomalla 2006) DRR is cost-effective. One dollar invested in DRR can save $2-10 in disaster response and recovery costs. (Mechler 2005) Disasters occur as a result of the combination of population exposure to a hazard; the conditions of vulnerability that are present; and insufficient capacity to reduce or cope with the potential negative consequences.

By reducing human vulnerability to disasters, we can lessen—and at times even prevent—their impact. Vulnerability may be lessened by: 1) reducing human exposures to the hazard by a reduction of human vulnerability, 2) lessening human susceptibility to the hazard, and 3) building resilience to the impact of the hazard. (Keim 2008) Public health disasters are prevented when populations are protected from exposure to the hazard. Public awareness and education can be used to promote a “culture of prevention” and to encourage local prevention activities. Public health disasters may also be mitigated through both structural and social measures undertaken to limit a health hazard's adverse impact. (IPCC 2007) Community-level public health can play an important part in lessening human vulnerability to climate-related disasters through promotion of “healthy people, healthy homes and healthy, disaster resilience communities.” (Srinivasan 2003)