To Örebro University

BACKGROUND: Emergency departments (EDs) are often the first point of contact for patients with sepsis, and therefore play a critical role in early recognition and treatment. However, the extent to which sepsis guidelines are implemented across EDs in Europe remains unclear, and variability in adherence may impact patient outcomes. OBJECTIVE: This study aimed to assess current sepsis management practices in European EDs, evaluate adherence to international guidelines, and identify key challenges limiting effective implementation.

METHODS AND DESIGN: A structured survey was developed by sepsis experts from the European Society for Emergency Medicine (EUSEM). The questionnaire included both quantitative and open-ended items and underwent iterative refinement through pilot testing to ensure clarity and relevance.

SETTINGS AND PARTICIPANTS: The survey was distributed to EUSEM members and national emergency medicine societies across Europe. Respondents included medical directors or designated sepsis specialists, with only one response requested per ED. RESULTS: A total of 402 EDs from 28 European countries participated in the survey. While most EDs (72.5%) reported having a sepsis protocol in place, less than half implemented regular monitoring or structured training measures. The 1-h sepsis bundle was described as moderately to highly challenging to implement by the majority of the respondents; just over half (55%) reported completing all its elements within 1 h of ED presentation. Key barriers included high patient volumes, insufficient staffing, and lack of standardized sepsis definitions, leading to delays in recognition and treatment. The results also highlighted concerns regarding increased broad-spectrum antibiotic use following the implementation of the 1-h bundle, emphasizing the need for a balanced approach that considers antimicrobial stewardship.

CONCLUSION: This survey establishes a benchmark for understanding sepsis management practices in European EDs, identifying substantial variations and challenges. Areas for improvement include enhanced training to follow protocols, improved monitoring systems that measure protocol adherence, and alignment with evidence-based guidelines.

BACKGROUND: Disaster medicine involves managing situations where medical needs exceed available resources. In Sweden, disaster medicine is not yet a mandatory component of the medical education. Since the introduction of a revised six-year medical curriculum in 2021, it is unclear how disaster medicine will be integrated into the new program. This study aimed to evaluate the status of undergraduate disaster medicine education in Swedish medical schools, the teaching methodologies employed, plans for future curriculum integration, and the extent of variation across universities.

METHODS: We conducted a comprehensive review of syllabi from all Swedish medical programs to identify the inclusion of disaster medicine. Additionally, semi-structured interviews were conducted with 13 representatives from all seven Swedish medical schools, including those responsible for disaster medicine education or members of the education boards. The interviews explored teaching methods, curriculum content, and plans for the new six-year program. Data were analysed using qualitative content analysis.

RESULTS: Disaster medicine is included in the curriculum of all Swedish medical programs; however, its content, extent, and teaching approaches vary. Lectures are the most common teaching method, with some schools incorporating case discussions, tabletop exercises, and disaster simulations. Most medical faculties plan to maintain or expand their disaster medicine curriculum. However, there is no formal collaboration between universities in developing or standardizing disaster medicine education for the new curriculum.

CONCLUSION: The current level of disaster medicine education in Swedish medical schools requires enhancement in both quality and scope. Variations between universities would need to be minimized to ensure a more consistent approach. Preliminary plans for the new six-year medical program suggest that disparities between universities may persist, underscoring the need for a coordinated effort in standardizing disaster medicine education at the undergraduate level.

AIM: This study explores HICGs' experience of disaster response during a terrorist-induced major incident major incident.

DESIGN: A qualitative descriptive design with individual semi-structured interviews was used.

METHODS: This was a qualitative study based on seven individual interviews. Participants were members of hospital incident command groups during a terror attack. The interviews were transcribed verbatim and analyzed using deductive content analysis. The SRQR checklist was used to report the findings.

RESULTS: The data created from the interviews identified barriers and facilitators for hospital response as well as aligned with previously established categories: Expectations, prior experience, and uncertainty affect hospital incident command group response during a Major Incident and three categories, (I) Gaining situational awareness (containing two subcategories), (II) Transitioning to management (containing three subcategories) and (III) Experiences of hospital incident command group response (containing two subcategories). In addition, the results suggest that an exaggerated response may have led to unanticipated adverse events.

CLINICAL TRIAL NUMBER: Not applicable.

INTRODUCTION: The burden of critical illness may have been underestimated. Previous analyses have used data from intensive care units (ICUs) only, and there is a lack of evidence about where in hospitals critically ill patients receive care. This study aims to determine the burden of critical illness among adult inpatients across hospitals in different global settings.

METHODS: We performed a prospective, observational, hospital-based, point prevalence and cohort study in countries of different socioeconomic levels: Malawi, Sri Lanka and Sweden. On specific days, all adult in-patients in the eight study hospitals were examined by the study team for the presence of critical illness and followed up for hospital mortality. Patients with at least one severely deranged vital sign were classified as critically ill. The primary outcomes were the presence of critical illness and 30-day hospital mortality. In addition, we determined where the critically ill patients were being cared for and the association between critical illness and 30-day hospital mortality.

RESULTS: Among 3652 hospitalised patients, we found a point prevalence of critical illness of 12.0% (95% CI 11.0 to 13.1), with a hospital mortality of 18.7% (95% CI 15.3 to 22.6). The crude OR of death of critically ill patients compared with non-critically ill patients was 7.5 (95% CI 5.4 to 10.2). Of the critically ill patients, 96.1% (95% CI 93.9 to 97.6) were cared for in the general wards outside ICUs.

CONCLUSIONS: The study has revealed a substantial burden of critical illness in hospitals from different global settings. One in eight hospital in-patients was critically ill, 19% of the critically ill died in hospital, and 96% of the critically ill patients were cared for outside of ICUs. Implementing the most feasible and low-cost critical care in general wards throughout hospitals would impact a large number of high-risk patients and has the potential to improve outcomes across all acute care specialties.

Background: Prolonged emergency department length of stay (EDLOS) is a worldwide issue associated with increased mortality, decreased patient satisfaction and poor quality of care. The factors influencing EDLOS have not been comprehensively studied in the context of Swedish EDs. This study's objective is to determine the input-, throughput- and output factors associated with EDLOS, at two urban EDs in Sweden.

Methods: Data was collected from two hospitals. All patient visits during the two-year study period were included. Patients who left without being seen by a physician were excluded. The explanatory factors included patient characteristics, medical data, and hospital bed occupancy data. Multi-variable linear regression analysis was used to test the associations between the factors and EDLOS.

Results: The top contributors to prolonged EDLOS were diagnostic imaging, which added between 64 and 149 min of EDLOS, diagnostic testing at central laboratory (53-99 min), followed by intra-ED zone transfer (46-94 min). Arriving during crowding or being admitted during high hospital bed occupancy had a significant but relatively small absolute effect on the outcome.

Conclusions: Throughput factors had far greater impact on EDLOS than both input- and output factors. Adapting strategies to the structural and procedural characteristics of each setting may enhance the effectiveness of improvement efforts.

Clinical trial number: Not applicable.

BACKGROUND: Sepsis is potentially fatal and commonly affects older people. However, little is known of the association between surviving sepsis and older patients' autonomy and dependency following hospital discharge.

METHODS: A population-based register study using data from five Swedish national registers included emergency department (ED) visits and in-hospital admission of patients aged 65 years of age and older years with infection or sepsis between 2013 and 2020. The consumption of home care services and residential care, as well as mortality, was examined 1, 6 and 12 months after hospital discharge using mixed models. FINDINGS: 166,188 ED visits with sepsis (23 %) and non-sepsis infections (77 %). Sepsis was associated with an increased risk of becoming dependent on home care (RR=1.09 [1.03-1.15]), residential care (RR=1.05 [1.0-1.1]) and mortality (RR=1.96 [1.89-2.03]) 12 months after in-hospital discharge compared to being diagnosed with infection only. The level of care one month prior to the index ED visit, among the study population, i.e., patients having attended the ED with sepsis and infection, was associated with risk of sepsis OR = 1.31 [1.27-1.35] for patients dependent on home care, and OR = 2.16 [2.09-2.23] for patients dependent on residential care as compared to patients independent on home care. INTERPRETATION: The current study suggests that sepsis is a major debilitating condition in older survivors, and many patients do not recover former dependency levels, one year after discharge as well as an increased mortality risk. Also, prior dependency on home care or residential care was a risk factor for sepsis for those patients who attended the ED with sepsis and infection. FUNDING: Funding was obtained through Örebro University, Sweden and the Research Committee of Region Örebro Län, Sweden.

Background: Workplace violence is a widely recognised problem within the ambulance service context. The causes of workplace violence have often been attributed to patient- or situation-related risk factors. However, there is a lack of research on workplace violence from the offender's perspective.

Aim: To explore workplace violence directed toward ambulance services from the offender's perspective.

Methods: An explorative qualitative study was conducted using inductive thematic analysis of trial transcripts from cases tried in court between 2013 and 2023. Plaintiffs in these cases were ambulance personnel or the ambulance service itself. Offenders were those convicted of committing or attempting any of the following acts: threats, theft, assault, molestation or murder.

Results: Twenty-three trial transcripts were analysed, and four themes were found: (I) the offender was misunderstood, which included communication problems and other misunderstandings; (II) the offender was disrespected, which described perceived unprofessional behaviour and unpleasant or painful treatment by ambulance personnel; (III) the offender was vulnerable, which described the state of the offender (i.e., being under the influence of alcohol or drugs); and (IV) the offender had unmet expectations, which included perceived unreasonable waiting time and conflicting expectations of ambulance care.

Conclusion: The analysis of trial transcripts revealed four themes from the offender perspective: feelings of being misunderstood, disrespected, vulnerable, and having unmet expectations. It is important to view these results critically, as they are based on trial transcripts in which the offender was found guilty of a crime and may have been attempting to defend his or her actions during the trial. Despite this caveat, healthcare professionals need also to recognise that their behaviour may influence the risk of workplace violence. This knowledge can be harnessed to develop training programs for ambulance personnel.

Background: Procedural sedation and analgesia is an important part of pediatric emergency care, safe and clinically useful alternatives for adequate management are necessary. The objective of this clinical trial was to evaluate the non-inferiority of intranasal dexmedetomidine to nitrous oxide with respect to analgesia for a painful procedure in children 3-15 years of age.

Methods: This prospective, equally randomized, open-label, non-inferiority trial was conducted at a Pediatric Emergency Department. Previously healthy children 3-15 years of age, with an extremity fracture or luxation or a burn and requiring procedural sedation and analgesia were eligible. Patients were randomized to receive either intranasal dexmedetomidine or inhaled nitrous oxide. The primary outcome measure was highest pain level during the procedure, assessed with Face, Legs, Activity, Cry, Consolability scale (FLACC). Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables) were used for statistical analysis.

Results: The highest FLACC was median 4 (IQR 3-6) with intranasal dexmedetomidine and median 4 (IQR 2-6) with nitrous oxide. The median of the difference between samples from each group for FLACC was 0 with 95%CI (0-1), thus intranasal dexmedetomidine was not inferior to nitrous oxide with respect to the level of pain during the procedure. The same method for procedural sedation and analgesia would be accepted by 52/74 (82.5%) children and 65/74 (91.5%) parents in the intranasal dexmedetomidine group respectively 59/74 (88.1%) versus 70/74 (94.6%) with nitrous oxide. No serious adverse events were reported.

Conclusions: The results of this trial support that intranasal dexmedetomidine is not inferior to 50% nitrous oxide in providing analgesia for a painful procedure in children 3-15 years of age and can be considered as an alternative to 50% nitrous oxide for procedural sedation and analgesia.

Trial registration: EudraCT 201,600,377,317, April 20, 2017. https://eudract.ema.europa.eu/.

BACKGROUND: Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine.

METHODS: This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1-3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents' satisfaction, and physician's assessment. Comparisons were done using Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables).

RESULTS: Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0-3) with intranasal dexmedetomidine and 5 (2-6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were "very satisfied" with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial.

CONCLUSIONS: This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1-3 years with minor injuries. TRIAL REGISTRATION: Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/.