Demand for prehospital emergency services has been increasing worldwide. Significant challenges exist in meeting response times in rural environments when faced with surges in demand related to weather events or sustained demand surge such as the pandemic environment. Significant pressure also exists in the hospital environment receiving such large volumes of patients with short duration handovers to allow prehospital assets return to their primary roles. The aim of this study is to determine trends for ambulance presentations in a rural emergency department over seven years with absolute numbers and percentage of overall attendances.

A retrospective analysis of anonymized electronic registration data on the iPMS system from initiation in 2014 to 2022 including total registration numbers, presentation by ambulance, and handover times. Excel is used to record and examine data.

ED attendances rose from 29,236 in 2014 to 43,184 in 2021 with total ambulance presentations ranging from 4,859 in 2014 (16.62% of attendances), maxing in 2019 at 10,326 out of total attendances of 42,637 (24.22% of attendances).Lowest monthly ambulance presentations occurred in April 2014 (441 or 15.82% of 2788 attendances) and maximal monthly presentations was 1,023 in May 2022 (23.38% of 4376 attendances). Lowest percentage of attendances arriving by ambulance occurred in May 2014 with 14.97% (468) out of 3,127 ED presentations. Highest percentage of attendances arriving by ambulance occurred in January 2021 with 33.67% (875) of 2,599 ED presentations which was during the lockdown phase of COVID in Ireland.

Overall total numbers of patients arriving by ambulance has been steadily increasing for years but numbers (and percentages) dramatically increased during COVID and this has been sustained in the POST Lockdown pandemic phase. Strategies are required to manage demand, increase turnaround and educate the public on appropriate use of prehospital emergency services.

Molecular assay for diagnosing and detecting SARS-COV-2 is an essential tool in pandemic management, allowing for early informed decision-making. Worldwide, the gold standard for testing SARS-COV-2 includes real-time reverse transcription-polymerase chain reaction assay (RT-PCR). The Cepheid Xpert-Xpress was authorized for emergency diagnosis of SARS-COV-2. This platform demonstrated various advantages, including faster results, due to a decreased turnaround time, and decreased contamination risk. However, inconclusive results often leave clinicians uncertain regarding individual patient management decisions. Often leading to more confusion than answers.

The aim of this literature review includes the following:

• identify the frequency and clinical implications of inconclusive results for SARS-COV-2 diagnosis utilizing GeneXpert assay

• whether inconclusive results should be interpreted as negative

• assessing the reliability of the GeneXpert platform to diagnose SARS-COV-2

A narrative literature review was conducted with eight critically appraised articles which met the inclusion criteria.

After the initial data collection, the SANRA Framework was implemented to aid in the sorting and filtering of data. The analysis of data was conducted with a critical appraisal tool.

The GeneXpert SARS-COV-2 assay demonstrated high sensitivity and specificity. Studies indicated that inconclusive results associated with a high cycle-threshold value (CT-value) of more than thirty-five on the Cepheid Xpert Xpress were associated with a decreased viral load and, thus, decreased infectivity. However, numerous factors influence the CT-value, such as specimen integrity. Thus, results must not be interpreted in isolation.

This narrative literature review demonstrated the need for institutions to assist clinicians with decision-making regarding inconclusive results. A flow diagram grading a patient’s risk of having SARS-COV-2 with an inconclusive result could be of immense value. The flow diagram should incorporate the current epidemiology in the area, patient symptomology and risk and duration of exposure.

The consequences of missed lower-limb deep vein thromboses (DVT) can be life-threatening. Similarly, inappropriate treatment with anticoagulation in low-risk patients carries a significant risk of harm. Early diagnosis and appropriate treatment with anticoagulation rely on timely ultrasound access. The National Institute for Health and Care Excellence (NICE) recommends timeframes for ultrasound acquisition based on Well’s score and D-dimer value.

If rapid ultrasound (Point of care Ultrasound POCUS in our context) demonstrates no features of DVT, it is safe to arrange follow-up scan within eight days without empiric anticoagulation. If, however, no bedside ultrasound is performed, anticoagulation is commenced until a formal scan excludes DVT. NG158 recommends this scan be performed within 24 hours. This audit investigated our compliance with NG158 time standards at Wexford General Hospital (WGH) emergency department (ED).

Electronic records for patients undergoing formal ultrasound for suspected DVT between 08/01/2022-10/13/2022 were reviewed using the hospital’s databases. Charts were reviewed to determine if POCUS was performed. In total, 42 records met selection criteria. Audit Committee governance review was obtained. Fisher’s exact test was used to compare compliance rates between those that underwent bedside ultrasound and those that did not.

Overall compliance with NG158 was 40.5%. Compliance rates for those offered bedside ultrasound were significantly higher than those that weren’t (58.3% vs. 16.7% p<0.0106). The mean waiting time for a radiology department ultrasound is six days, 12 hours, and 16 minutes.

Overall compliance is low, and delays to obtaining formal ultrasound are long. We observed that compliance rates for those who underwent bedside ultrasound were significantly higher than for those who did not. This suggests that bedside ultrasound is under-utilized in our ED. Training more staff to perform bedside scans would alleviate current delays to ultrasound diagnosis and reduce risks associated with empiric anticoagulation.

The National Ambulance Service (NAS) must transport patients with acute psychiatric needs to their nearest emergency department for assessment. Wexford General Hospital (WGH) does not have on-site medical psychiatric services after hours, in-patient psychiatric beds, or dedicated psychiatric doctors. Patients requiring formal acute psychiatric assessment and/or admission after ED review need to be transferred 60-80 km to other healthcare facilities.

Aimed to assess average ED stays of psychiatric patients and determine what degree transfer time contributed to their total time would help to determine what delay there was to providing acute psychiatric care due to the lack of after hours/on-site services.

Data was collected from the iPMS system. A total of 125 patients presented with primary psychiatric complaints between January 1, 2021 and December 31, 2021 and required onward transfer for acute psychiatric assessment or admission. Patients were excluded if less than 18 years or had been admitted to another WGH service before transfer. There are no existing guidelines in the National Clinical Program for Psychiatry or NICE guidelines for acute psychiatric patient transfer times or ED stays.

The average WGH ED attendance time was 15h 27min (range 0h08min and 19h22min). The longest interval contributing to overall time was Transfer Booked to Transfer Time (average 3h 27min). The time from Psychiatric Referral to Transfer accounted for 30% (on average) of patients’ attendance time.

There are significant delays in accessing acute psychiatric care due to the absence of Ambulance Service Bypass Protocols to transport patients to the most appropriate rather than the nearest ED. Proposed Trauma bypass system changes offer unique opportunities to review such inequity of access to acute psychiatric services.

As the population in the Republic of Ireland increases, the number of Emergency Department (ED) attendances and admission rates increase, placing significant pressure on the health care system, the limited staff and hospital resources.

The aim of this study is to assess the admission rates in an Irish Public Hospital Emergency Department between 2014 and 2022.

This retrospective study was done using information provided by the Health Service Executive Integrated Patient Management System. Data for the period between February 2014 to September 2022 were collected. From the data, the admission rate can be calculated and trends observed.

Emergency department attendance rates have increased from 29,236 to 42,637 between 2014 and 2019, with a decline noticed in 2020 to 37,751 and a drastic increase in 2021 at 43,182. Currently up until September 2022 there has been 35,503 attendances and 8,570 admissions, with an admission rate of 24.14%. The number of admissions has ranged from 9,056 in 2014 to the highest being 12,175 in 2019. This means the admission rate is averaging between 24% to 31% per annum, with the highest being 31,04% in 2015, and the lowest in 2017 at 24,99%.

This study showed a steady increase in attendances per annum, which correlates to an increase in the total admissions from 2014 to 2022, with approximately one third of all ED attendances resulting in admission. The increase in attendances and admission rate could be related to the population growth from 4.6 to 5.1 million from 2014 to 2022. The decrease in attendances during 2020 could be attributed to the Covid-19 pandemic restrictions being implemented, and lifted in 2021 which showed a drastic increase in ED numbers. Ultimately, the increase in admissions will place a burden on the Public Hospitals in Ireland.

Trauma is one of the leading causes of death in patients under 40 years of age. The Advanced Trauma Life Support (ATLS) Guidelines are widely accepted as the standardized approach to trauma and classify hemorrhagic shock according to heart rate (HR), blood pressure (BP), urinary output, and mental status. Paradoxical bradycardia (defined as HR <60 bpm) in hemorrhagic shock is an uncommon presenting feature and presents a diagnostic challenge to the physician; its true incidence is unknown.

A case of paradoxical bradycardia was examined as a presenting feature in hemorrhagic shock.

A 17-year-old male patient presented to our Emergency Department (ED) with collapse and abdominal pain following a collision with another player during a sports match.

The patient was hypotensive (BP 92/42) and bradycardic at triage, with a heart rate of 50. He was pale and diaphoretic with a Glasgow Coma Scale of 13/15, thready pulses, and localized peritonitis in the left upper quadrant of his abdomen.

An increase in blood pressure was observed following initial fluid resuscitation; however, this was transient and preceded the onset of profound hypotension (BP 64/30). Bradycardia with a heart rate between 50-60bpm was persistent despite resuscitative efforts.

Abdominal ultrasound demonstrated intraperitoneal free-fluid, and Computerized Tomography confirmed the presence of a grade V splenic laceration. He was taken to the operating theater for emergency laparotomy and underwent splenectomy. A 2.3 liter hemoperitoneum was found intraoperatively. There were no further complications post-operatively, and he made a full recovery.

Tachycardia is a potentially unreliable marker of blood loss, especially in young, healthy patients. A high index of suspicion is necessary to prevent this uncommon but life-threatening feature of hemorrhagic shock from being overlooked.

Ultrasound is the standard imaging technique for diagnosing lower limb deep venous thrombosis (DVT). The National Institute for Health and Care Excellence (NICE) guidance 158 recommendation 1.1.3 states that all patients with sufficient pretest probability for DVT should be offered a proximal leg vein ultrasound within four hours. However, due to high patient volumes, formal radiology department ultrasound wait times often exceed one week. Point-of-care ultrasound (POCUS) is used to bridge diagnostic delay in our emergency department (ED) .

This study aimed to quantify numbers offered POCUS for suspected proximal lower DVT in our ED and accuracy of such studies.

A retrospective review of electronic records was conducted for patients who underwent formal lower-limb ultrasound for suspected DVT at our hospital over a three-month period (August 1, 2022-October 12, 2022). Patient charts for all ED presentations were assessed to determine whether POCUS was offered and whether DVT was diagnosed.

Statistical analysis was conducted using PRISM v9.

80 formal ultrasound scans were performed at our hospital for lower limb DVT. 58 were requested for patients presenting to ED, of which 42 had complete records available meeting selection criteria.

POCUS was offered to 24 patients in ED (57.1%). Sensitivity was 66% (95% CI 12%- 98%), and specificity was 94.1% (95% CI 75%-99%). Overall accuracy was 90%, with only one false negative study identified at formal follow-up ultrasound.

Although sample size was small, our results suggest that POCUS is an accurate but underused tool to diagnose lower limb DVT. Developing a standardized protocol for performing and reporting POCUS DVT scans in ED should allow for earlier diagnosis and initiation of appropriate treatment where necessary.

Health service capacity has been an issue in Ireland since the 1980s swinging cuts. Government reports from 2003 have consistently identified a requirement for 3,000-5,000 extra beds on top of the current approximately 10,500 capacity. Acute hospital bed capacity issues have escalated, the formal system of recording “over capacity” patients or “patients on trolleys” has developed. A “Trolleygar” reports issues from the Health Service Executive (HSE) three times daily. This count is an underestimate as patients temporarily housed in day care units, surgical, or medical assessment units, discharge lounges and other clinical areas which have a bed space are not counted in this overcapacity measure. This study's aim is to calculate the annual number of days on which no patients were lodged on trolleys in Wexford General Hospital.

Descriptive study using anonymized freely available data from the national HSE Trolley GAR reports on trolley patients in Wexford General Hospital from January 2019 until September 2022. A Golden Zero trolley day was stated as a day on which there were no reported trolley-patients at the three time points, Silver Zero trolley day when two of the time periods recorded no trolleys and a Bronze Zero Trolley day when one period recorded a zero trolley count.

Data was collected on 1,369 days, with 90 days excluded due to missing data sets. There were 162 Golden days recorded (12.67% of total days). The year 2020 recorded the highest number of Golden days at 28.69% (105 days), followed by 2021 with 11.23% (41 days). During 2019 there were 3.84% (14 days) Golden days and 2022 had the lowest number (January-September) with 0.73% (2 days).

Despite a zero-tolerance policy, Golden days are disappearing rapidly, capacity is urgently required with post-pandemic ED attendance surges worldwide. True recording of overcapacity patients is required for appropriate capacity modeling.

COVID-19 resulted in 1.8 million reported deaths in 2020 and an excess mortality of at least 3,000,000 to date. Following the announcement of emergency measures mandating various public health interventions, international studies demonstrated a decline in ED attendances, potentiating a delay in seeking health services.

The objective was to examine ED attendance trends by age group and to categorize the attendances following the implementation of regulations related to COVID-19.

A single-center retrospective observational study of ED attendances from 2014 to 2022 at Wexford General Hospital, a 225-bed acute general hospital. Monthly attendance trends were analyzed covering all phases of the national response. Information was extracted from the electronic health record system iPMS.

Overall attendances decreased by 11.5% {42,637 (2019) to 37,751 (2020)}, well below expected annual growth projections from 2019 to 2020. A significant reduction in pediatric attendance (≤16 years) occurred, with 31.68% negative growth (10,351 to 7,071) in 2020 and sustained decrease of 15.3% (8,767 attendances) in 2021. In contrast, geriatric (≥65 years) attendances were unchanged in 2020 (17,751), with a surge of 8.9% to 19,333 attendances in 2021, the largest year-on-year growth since 2018. Comparisons of month-to-month trends in relation to public health measures correlated to a marked decline in attendances at the extremes of age during “lockdown” periods.

The reduction in attendances is likely multifactorial, such as a reduction in school-related stress and patients deciding to stay home for fear of attending during the pandemic with non-emergent conditions. The increase in geriatric presentations in 2021 may reflect continuing restricted access to primary care and GP services, or neglect of prior conditions. Examining changing demographic attendances may offer opportunities to develop alternative ways of supporting frail populations and families in community care avoiding ED presentations.

Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).

A 2018–2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.

In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.

Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.

The primary objective of this study was to co-design and conduct a pilot evaluation of a novel, immersive virtual reality (VR) experience for procedural pain and anxiety in an Australian healthcare setting. The secondary objective was to identify key parameters that can facilitate the development and implementation of VR experiences in clinical practice.

A qualitative, Design Box method was selected for co-design. It was used with adult burns survivors and adolescents and young adults (AYAs) with cancer, and healthcare professionals from these fields to identify the practical and design parameters required for the application of VR technology within the clinical setting. Results informed the development of the VR experience that was evaluated by consumers and healthcare professionals, who completed qualitative surveys. Thematic analysis was conducted on co-design notes and survey data.

Procedural pain and management was a challenge for both cohorts, but particularly the burns cohort. Anxiety was significant challenge for both cohorts. Boredom and quality of life was a significant challenge, particularly for the AYA oncology cohort. These results informed the development of “A Wanderers Tale,” an Australiana-themed, gaze-controlled VR application for Oculus Quest platforms. Thematic analysis results suggest that cultural preferences, procedural contexts of use, and agency through customization and interaction are three parameters to consider when creating or selecting VR experiences for application in health.

This work describes a novel method for the use VR as an adjuvant pain management tool in patients with burns and cancer. The VR experience may provide a culturally, practice and procedure-appropriate tool in comparable settings of care. The study also describes interdisciplinary co-design and evaluation approaches that can help maximize the use of VR to improve healthcare approaches that address clinical challenges in pain, anxiety, and quality of life for patients while in hospital.

Anorexia nervosa (AN) is a psychiatric disorder with complex etiology, with a significant portion of disease risk imparted by genetics. Traditional genome-wide association studies (GWAS) produce principal evidence for the association of genetic variants with disease. Transcriptomic imputation (TI) allows for the translation of those variants into regulatory mechanisms, which can then be used to assess the functional outcome of genetically regulated gene expression (GReX) in a broader setting through the use of phenome-wide association studies (pheWASs) in large and diverse clinical biobank populations with electronic health record phenotypes.

Here, we applied TI using S-PrediXcan to translate the most recent PGC-ED AN GWAS findings into AN-GReX. For significant genes, we imputed AN-GReX in the Mount Sinai BioMe™ Biobank and performed pheWASs on over 2000 outcomes to test the clinical consequences of aberrant expression of these genes. We performed a secondary analysis to assess the impact of body mass index (BMI) and sex on AN-GReX clinical associations.

Our S-PrediXcan analysis identified 53 genes associated with AN, including what is, to our knowledge, the first-genetic association of AN with the major histocompatibility complex. AN-GReX was associated with autoimmune, metabolic, and gastrointestinal diagnoses in our biobank cohort, as well as measures of cholesterol, medications, substance use, and pain. Additionally, our analyses showed moderation of AN-GReX associations with measures of cholesterol and substance use by BMI, and moderation of AN-GReX associations with celiac disease by sex.

Our BMI-stratified results provide potential avenues of functional mechanism for AN-genes to investigate further.

Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.

To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.

Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.

Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.

AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.

With improvements in early survival following congenital heart surgery, it has become increasingly important to understand longer-term outcomes; however, routine collection of these data is challenging and remains very limited. We describe the development and initial results of a collaborative programme incorporating standardised longitudinal follow-up into usual care at the Children’s Hospital of Philadelphia (CHOP) and University of Michigan (UM).

We included children undergoing benchmark operations of the Society of Thoracic Surgeons. Considerations regarding personnel, patient/parent engagement, funding, regulatory issues, and annual data collection are described, and initial follow-up rates are reported.

The present analysis included 1737 eligible patients undergoing surgery at CHOP from January 2007 to December 2014 and 887 UM patients from January 2010 to December 2014. Overall, follow-up data, of any type, were obtained from 90.8% of patients at CHOP (median follow-up 4.3 years, 92.2% survival) and 98.3% at UM (median follow-up 2.8 years, 92.7% survival), with similar rates across operations and institutions. Most patients lost to follow-up at CHOP had undergone surgery before 2010. Standardised questionnaires assessing burden of disease/quality of life were completed by 80.2% (CHOP) and 78.4% (UM) via phone follow-up. In subsequent pilot testing of an automated e-mail system, 53.4% of eligible patients completed the follow-up questionnaire through this system.

Standardised follow-up data can be obtained on the majority of children undergoing benchmark operations. Ongoing efforts to support automated electronic systems and integration with registry data may reduce resource needs, facilitate expansion across centres, and support multi-centre efforts to understand and improve long-term outcomes in this population.

Clinical databases in congenital and paediatric cardiac care provide a foundation for quality improvement, research, policy evaluations and public reporting. Structured audits verifying data integrity allow database users to be confident in these endeavours. We report on the initial audit of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry.

Participants reviewed the entire registry to determine key fields for audit, and defined major and minor discrepancies for the audited variables. In-person audits at the eight initial participating centres were conducted during a 12-month period. The data coordinating centre randomly selected intensive care encounters for review at each site. The audit consisted of source data verification and blinded chart abstraction, comparing findings by the auditors with those entered in the database. We also assessed completeness and timeliness of case submission. Quantitative evaluation of completeness, accuracy, and timeliness of case submission is reported.

We audited 434 encounters and 29,476 data fields. The aggregate overall accuracy was 99.1%, and the major discrepancy rate was 0.62%. Across hospitals, the overall accuracy ranged from 96.3 to 99.5%, and the major discrepancy rate ranged from 0.3 to 0.9%; seven of the eight hospitals submitted >90% of cases within 1 month of hospital discharge. There was no evidence for selective case omission.

Based on a rigorous audit process, data submitted to the PC4 clinical registry appear complete, accurate, and timely. The collaborative will maintain ongoing efforts to verify the integrity of the data to promote science that advances quality improvement efforts.