Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, October 2016

Objective: Physician Associates were employed in a busy London Emergency Department to provide a new level of integrated Emergency Medical care.

Background: Physician Associates have proved invaluable in the USA medical field over the past 30 years and have been identified as a possible workforce solution in the UK1,2. There are currently 19 Physician Associates (PAs) working in Emergency Departments across the UK3, with the aim of improving the ED staffing crisis.

Case Description: Two Physician Associates were employed in a London Emergency Department 18 months ago, initially to assist in the Observation ward previously run by locum SHO's. As well as providing permanent, reliable junior staff members, this also alleviated the expenditure on locums in the Observation Ward at approximately half the cost per year. Despite initial skepticism, the role has developed following structured teaching sessions and reliable support from a designated consultant. A vigorous appraisal system was instigated with the clinical supervisor to ensure that the PAs’ clinical skills were developing appropriately and the PA's now see new unselected patients in the ED. The PAs also contribute to achieving CQUIN targets within the department by completing VTE assessments and discharge summaries. All patients in the observation ward now receive a senior review by either a Consultant or Registrar within 12 hours of admission - improving patient outcome. Research shows that patients do not mind whether they are seen by a PA4 and the role has been well received.

Conclusion: PAs have been so well received in the department that there has been a proposal to employ further individuals as a workforce solution. Doctors who work regularly with PAs are pleased with the role5. This model could be used in other hospitals to help with staffing pressures and also reduce cost of employing locums.

Background: On 3rd March the local newspaper published report regarding measles outbreak in Mansehra Colony Landhi, Karachi. In response to the report the Executive District Office health Karachi constituted a three members investigating team with the objectives to investigate the outbreak and propose recommendations for control of outbreak the affected Mansehra Colony Landhi having population of 600 households.

Methods: Investigation was carried out from 4th to 7th March, 2015. Case was defined as a child having 15 years of age residing in Mansehra Colony Landhi, with: a generalized rash and fever for three or more days and one or more of the associated symptoms, including cough, or coryza or conjunctivitis from 1st March to 7th March, 2015. Active case finding was carried out, line list maintained and six blood samples were taken and shipped to NIH Islamabad for lab confirmation.

Results: Sixteen cases were line listed, out of which 75% (n = 12) were females. Median age was 9 years (range: 3 to 13 years). All cases were from same family. Index case was 6 years old girl who visited her parents at Balochistan province (measles endemic) 6 days prior to development of sign symptoms. NIH Lab confirmed four cases positive out of six. As per EPI record all cases were fully immunized against measles.

Conclusion: Cases appeared in vaccinated children implicate that either there is some problem with the quality of vaccine, cold chain maintenance or vaccination techniques. Mopping -up activities conducted in Mansehra colony Landhi and surroundings, Health Education sessions conducted by Lady Health Workers on hygiene and disease prevention.

Keywords: measles outbreak, vaccinated, Health Education

Introduction: Diabetic foot is one of the most disabling complications with substantial morbidity. It remains the most common reason for hospital admission, impairs quality of life, engenders high treatment costs and is the most important risk factor for amputation.

Objectives: To determine the prevalence of diabetic foot among diabetic patients and the prevalence of main related risk factors.

Methods: A cross-sectional study was performed in Specialized Center for Diabetes in Baghdad - Iraq in which 410 diabetic patients age range 30–83 years were selected using convenient sample from 1st June - 31st September 2013. Data was collected by direct interview using a questionnaire, physical examination, patients' records and laboratory investigations. The data was analyzed using Minitab software version 16.

Results: Among 410 diabetic patients, females (56.83%) and males (43.17%). The prevalence of diabetic foot among diabetic patients was 19.27%. The following risk factors showed a statistically significant association with diabetic foot development: male gender (P = 0.047), duration of diabetes mellitus (P = 0.001), history of bare foot (P = 0.001), non-self-cleaning of foot (P = 0.001), hypertension (P = 0.006), irregular visits to diabetes center (P = 0.016) and uncontrolled level of HbA1c (P = 0.001). Applying binary logistic regression analysis revealed an independent significant association with diabetic foot development with: history of barefoot (AOR = 2.95), non-self-cleaning of foot (AOR = 2.24), male gender (AOR = 2.17), duration of diabetes mellitus (AOR = 1.37) and uncontrolled level of HbA1c level (AOR = 5).

Conclusions and recommendations: There is a high prevalence of diabetic foot among diabetic patients. The study recommends implementing the knowledge of main risk factors into preventive policies and investing more financial support on training programs in primary health care and specialized centers, patient education and DF problem awareness programs.

Background: It has been found that 89% of the ED staff in HGH has very low knowledge on the approach of SBAR, due to which they don't converse it accordingly with other staff especially during endorsements, face-face & critical call scenarios.

Aim: To increase and standardize the usage of SBAR as a communication tool among the clinical staff in the ED of high to 100% by FEB 2016.

Methods: The project was done in an iterative four-step continuous improvement method through careful monitoring in various areas of ED to collect the baseline data. SBAR champions were chosen from each area to facilitate and coordinate the project to most of ED. SBAR endorsement form was introduced for the nurses between shifts to notify information. Nurse educators & quality reviewers decided on educational sessions for the ED-nurses which consisted of role play, scenario based & simulation training for the nurses to make them understand the relevance of SBAR. A monitoring tool was developed for secret audit on SBAR usage to know the efficacy in the area.

Results: There has been a spike in the usage of SBAR by the nurses during the endorsement time and between the work schedules. With the help of the CN's and SBAR champions who regularly change from day to day, Careful monitoring has been placed in various areas of the ED which has led to such significant achievement. As of now the measurement and the testing has been done with the nurses, physicians, ECG technicians, respiratory therapists and also the quality reviewers. we are soon planning to include ems for the same training by end of February, we will make sure the whole ED will be talking & reporting in SBAR.

Conclusions: Interprofessional communication activity is needed at the entry level for all professionals. SBAR - teachable skill that is recognized by all healthcare workers as safe effective method of communicating among providers. We will soon spread this communication between units & during transfers also. Registration number: 0000-0003-0866-6512.

Background: Acute respiratory infections, including influenza, comprise a leading cause of morbidity and mortality globally. Influenza surveillance provides important information to inform policy on influenza control and vaccination. While the epidemiology of influenza has been well characterized in western countries, few data exist on influenza epidemiology in the Eastern Mediterranean Region. We describe the epidemiology of influenza virus in Oman.

Methods: Using syndromic case definitions and protocols, patients from four regional hospitals in Oman were enrolled in a descriptive prospective study to characterize the burden of severe acute respiratory infections (SARI) and influenza. Patients meeting the SARI case definition provided demographic information as well as oropharyngeal and nasopharyngeal swabs. Specimens were tested for influenza A and influenza B. Influenza A viruses were subtyped using RT-PCR.

Results: From January 2008 through June 2013, a total of 5,147 cases were enrolled and tested for influenza. Influenza strains were detected in 8% of cases for whom samples were available. Annual incidence rates ranged from 0.5 to 15.4 cases of influenza-associated SARI per 100,000 population. The median age of influenza patients was 6 years with children 0–2 years accounting for 34% of all influenza-associated hospitalizations. By contrast, the median age of non-influenza SARI cases was 1 year, with children 0–2 years comprising 59% of SARI. Compared to non-influenza SARI cases, a greater proportion of influenza cases had pre-existing chronic conditions and underwent ventilation during hospitalization.

Conclusions: Influenza virus is associated with a substantial proportion of SARI in Oman. Influenza in Oman approximately follows northern hemisphere seasonality, with major peaks in October to December and a lesser peak around April. The burden of influenza was greatest in children and the elderly. Future efforts should examine the burden of influenza in other potential risk groups such as pregnant women to inform interventions including targeted vaccination.

Background: This study used the 2012 London Olympic Games as the empirical context to examine how interagency collaboration took place among the diverse public health and safety agencies involved in this mass gathering event. In order to develop our understanding of how collaboration among the key stakeholders in a mass event may be improved, this study aims at capturing the components that affected the ability of interagency collaboration to deliver its potential.

Methods: An exploratory case study design was used. Data were collected before, during and after the Games through semi-structured interviews, direct observations and documentary analysis. Template analysis was used to analyze the interviews' transcripts, the field notes from observations and the documents. The analysis generated a framework of factors influencing interagency collaboration including leadership, communication, governance and knowledge.

Results: Leadership shaped interagency collaboration through several characteristics including processes, skills, behaviours and relationships. Findings indicated that accountability issues, the use of guidelines and legislation and the physical presence of the leaders were perceived as fundamental to the implementation of effective collaboration. Effective leaders were supportive, persistent, good listeners and easy to talk. Moreover, interpersonal trust formed the basis for positive interagency collaboration.

Conclusion: Recognizing and understanding the above leadership characteristics is an important step towards the support of the collaborative endeavours in mass gathering events.

Background: The aim of this study was to evaluate post-injury functional recovery over three years in patients with moderate and major trauma in Hong Kong.

Methods: This is a multicentre prospective cohort study conducted in Hong Kong. The inclusion criteria were: trauma patients admitted to one of three trauma centres, with age ≥ 18 years, injury severity score (ISS) ≥ 9, meeting Trauma Registry criteria, and surviving to 48 hours. Functional outcome was measured by the extended Glasgow Outcome Scale (GOSE) at 3 years post-injury. Good outcomes were defined as an extended Glasgow Outcome Scale (GOSE) ≥ 7, i.e. trauma patients' status rated as lower good recovery or upper good recovery categories.

Results: From 1st January 2010 to 30th September 2010, 400 patients were included. Mean age was 53.3 years; range 18–106 years; and 70% were male. 139 (35%) patients had ISS 9–15; 261 (65%) patients had ISS ≥ 16. Among those included, 38 % required ICU admission; and 58% had healthy pre-existing comorbidity status. For the GOSE analysis, the number of surviving responders at 3 years post-injury reaching a GOSE ≥ 7 was 86, which represented 54.1% of the 159 surviving responders, and 21.5% (86/400) of the original cohort. As there were no statistically significant differences between surviving responders and non-responders at baseline, the assumption is made that 54.1% of the 167 non-responders (N = 90) also reached a GOSE ≥ 7. The total number of cases reaching a GOSE ≥ 7 is therefore estimated to be (86+90), or 176, which is 44.1% of the original 400 cases.

Conclusion: The proportion of cases reaching a GOSE ≥ 7 at 3 years post-injury is 44.1%.

Background: There is little evidence of research outcome data or studies into self-reported back pain in Middle Eastern or Gulf region countries. Within HMC there is anecdotal evidence that suggests that back pain in nurses working in critical care environments accounts for a significant percentage of all sick cause leave. This has the potential to impact on productivity, patient care and quality of life in nurses working within critical care in environments.

Methods: A cross center mixed methodology study looking at back pain in nurses working in critical care environments data collection included demographic, occupational, and health characteristics and a Likert questionnaire. This comprised of 10 questions relating to manual handling education, equipment, staffing levels and ergonomics and was distributed in critical care and emergency departments across five hospital sites responses rate n = 450.

Results: Outcome data identified 65% of the respondents reported experiencing back pain over the last year with subsequent negative impact on quality of life. There was statically significant association between gender and quality of life p = 0.001; with more women verbalizing a negative impact on quality of life secondary to back pain. There were also statically significant relationships between age with younger age group reporting negative impact on quality of life p = 0.001 and length of time employed in HMC with respondents who have been employed between 1–5 years experiencing the greatest impact p = 0.001.

Conclusions: Back pain is an under reported occupational health concern that impacts on productivity and quality of life. Mandatory training in manual handling should feature in corporate educational agenda. Occupational health initiatives' are essential in the management of chronic health conditions.

Emergency Medicine (EM) is an officially recognized medical specialty in over 60 countries, with the rate of specialty recognition accelerating in recent years. EM care delivery systems are specifically focused on managing the acute consequences of non-communicable as well as communicable disease processes, and therefore represent an important public health tool for reducing the present and future global. According to the 2006 World Health Organization studies on the Global Burden of Disease, worldwide demographic and epidemiologic shifts now show non-communicable diseases to have become the single largest cause of morbidity and mortality worldwide. At Max Health Care, George Washington University started a 3 years Master course in Emergency (MEM International) since 2008.

Aim: Efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. Primary objective: Has MEM Educational program at Max Health Care brought an Improvement in patient care in Max Emergency Department? Secondary objective: Factors which can help in Improving Quality of course. Inclusion criteria: Consultants of any Specialty worked for more than 2 years in Max Health care. Exclusion criteria: Senior resident and Junior resident of other specialty Incompletely filled survey form.

Methods: It was an observational study and questionnaire in Annexure 1 was used for the survey. The questionnaire will be given to 49 consultants of various departments in Max Group. Data has shown that 91.86% of Consultants have accepted that the course has brought improvement. Private Health sector has accepted Emergency Medicine as an Individual Specialty. 4 areas of suggestion turned up at final assessment: More hands-on training in Ultrasound Gynecology, Pediatrics and Anesthesia - advised more dedicated training time in their specialties Internal Medicine and Critical Care suggested follow up till discharge. Increased emphasis on communication skills.

Oman has committed to the goal of eliminating measles, rubella and congenital rubella syndrome (CRS) by 2015 year. Elimination is defined as the absence of endemic measles and rubella transmission in a defined geographical area for ≥ 12 months in the presence of a well-performing surveillance system and for rubella without the occurrence of CRS cases associated with endemic transmission in the presence of high-quality surveillance system. Strategies to reach this goal included: a) achieving and maintenance high rates of vaccination coverage; b) syndromic surveillance programs to monitor fever and rash illness syndromes for effective detection of cases; c) and high-quality surveillance system, and sensitive for CRS. Measles and rubella was a leading cause of infant and child morbidity and mortality in Oman before the introduction of measles vaccine by 1975 and thereafter until 1994. With the introduction of a second dose of measles and first rubella vaccines in 1994, coverage for first and second doses of measles and rubella vaccines increased more than 95% in 1996 and has been sustained thereafter. A national measles and rubella immunization catch-up campaign targeting children ages 15 months to 18 years was conducted in 1994 that achieved 94% coverage. As a result, the incidence of measles and rubella have declined markedly in recent years, to ≤  1 case per million persons in 2012 and to zero cases for measles and rubella in 2013. Similarly, no case of CRS has been notified since 2007. Oman has made significant progress toward measles and rubella elimination and has met the regional elimination goals. However, new challenges faced by Oman, for instance with increased globalization, has led to issues such as outbreaks from imported cases. Additional challenges still remain with regard to increasing identification and immunization of unvaccinated non-Omani workers and their families.

Introduction: MVC accident is one of the major cause of mortality and morbidity in children. In 2010, road traffic accidents were the major cause of 228 deaths and 568 major injuries in Qatar.(4). Children in cars who are not restrained, have a great risk of being injured. Our aim from this study is to check parents' awareness of the important of using child restrain (car seat) and reasons behind preventing them from not using it.

Objectives: Check parents' awareness of using car seat in Qatar. And do they know related information about installing car seat in their car and how to use it? Methods: A prospective cross sectional qualitative survey study was conducted at PEC Alsadd of Hamad Medical Corporation from (May 1st 2015 to October 31st 2015). A total number of 212 sample questionnaires were filled by parents whom visited PEC because of their children illness. All have been given survey questionnaire to fill while they are in waiting area. Then research assistants collect filled questionnaires.

Results: Distribution of Male: female is 40.6% (86) and 59.4% (126) 70.8% (150) have car seat and 29.2% (62) have no car seat. The Qatari: non-Qatari population is 10% (21): 90% (121) in the study. Among the Qatari respondent, 85.7% (18) have car seat and 14.3% (3) have no car seats. 12% of cases were children with chronic illness. 84% parents have 4wd cars. 80% of parents have university certification, though only 65% of them who have car seat. And 31% of them who use always car seats.

Conclusion: This study showed the importance of doing more parents education about the importance of using car seats.

Background: Cranial computed tomography (CT) scan is a commonly performed neuroimaging prior to lumbar puncture (LP) in children with suspected meningitis to rule out intracranial hypertension or space occupying lesions. The purpose of this study was to assess the accuracy of physicians' prediction of CT abnormal cerebral findings in pediatric meningitis.

Subjects and methods: A prospective observational study design was performed over a 12-month period. Eligible patients were admitted to the Emergency Department (ED) where a structured questionnaire was filled independently by two physicians before undergoing cranial CT scan and prior to LP.

Results: In this study, 72 patients met the inclusion criteria with a mean age of 7.04 ± 3.38 years. The mean physicians' prediction score of abnormal CT findings was 6.0 ± 3.0 vs. 2.48 ± 2.01 of no abnormalities (difference 3.5 ± 1.0 (95% CI: 1.5, 5.5; p = 0.001). Relative risk of CT abnormalities associated with decreased level of consciousness was 7.33 (95% CI: 1.5, 33.67), Glasgow coma scale was 23.3 (95% CI: 7.7, 70.7), and abnormal posture was 8.9 (95% CI: 1.9, 41.7). Apart from mild headache (2.8%), vomiting (2.8%), dizziness (4.2%), no serious complications related to LP procedure have been reported.

Conclusion: Physician's clinical decision could predict absence of abnormal findings on cranial CT scan before LP in children with suspected meningitis. Our results suggest that LP could be performed with avoidance of CT scanning of the head in pediatric meningitis provided the presence of normal consciousness level, Glasgow coma scale ≥ 13 and normal neurologic examination.

Endoscopic third ventriculostomy (ETV) is a common minimal-invasive neurosurgical procedure with well-documented complications. We report the case of a 6-year-old female child who underwent ETV, external ventricular drainage (EVD) catheter insertion and biopsy for a tumour arising from the pineal gland causing obstructive hydrocephalus and raised intra cranial pressure (ICP). Vital signs were stable pre-operatively and anaesthesia was maintained using propofol infusion. The operative bed was irrigated with normal saline under pressure after ETV, which immediately resulted in sinus tachycardia intra-operatively and central neurogenic hyperventilation (CNH) with respiratory alkalosis and transient lactic acidosis an hour after the surgery. Only few case reports have been reported in adults with CNH and respiratory alkalosis. Hyperventilation resulting in lactic acidosis is a well-known entity but lactic acidosis following CNH due to transient hypothalamic dysfunction after endoscopic third ventriculostomy has not been reported previously. Our patient was managed with benzodiazepines and oxygen delivered by a rebreathing mask, which resulted in complete recovery within 12 hours. This case highlights the importance of ICP measurement and monitoring and assessment of the type, volume and pressure of fluid used for brain irrigation during ETV, to prevent complications. ETV may cause intra-operative hemodynamic disturbances such as tachycardia, hypertension and hyperthermia followed by post-operative transient hypothalamic dysfunction and CSF acidosis leading to sequelae of CNH with acute respiratory alkalosis and transient lactic acidosis. We emphasize the importance of ICP monitoring during neuroendoscopic procedures, as an inadvertant rise in ICP appears to be the central factor leading to the various ill effects encountered both intra and post-operatively. Moreover, although normal saline has been the irrigation fluid of choice for neurosurgeons, a multitude of laboratory studies suggest it being less ideal and it might be prudent to look into alternatives, namely artificial CSF and Ringer's Lactate.

Introduction: Proteinuria in burn patients is common, and it could be associated with acute kidney injury (AKI) with bad outcomes. We evaluated the incidences, outcomes, characteristics and determinants of proteinuria as a biomarker and its influence on AKI and outcomes in burn patients.

Methods: This retrospective study was carried out on a group of patients with burn injuries admitted though Emergency Department to burn unit of Hamad General Hospital during a five-year period. Positive urine analysis (R/M) readings were defined as mild ( ±  or 1+) or heavy ( ≥  2+) proteinuria, and AKI was diagnosed and staged according to the Risk, Injury, Failure, Loss, End Stage (RIFLE) classification system. Patient characteristics, management and outcomes were evaluated as well for associations with proteinuria.

Results: Of the selected admitted patients to the burn unit during the study period (n = 249), 86 (34.5%) were classified as having proteinuria. In the patients whose total burn surface areas (TBSA) were > 30% (n = 50), 37 patients (74%) had proteinuria and 27 of these patients (72.9%) met AKI criteria. No patients without proteinuria developed AKI. Intensive care unit (ICU) mortality rates were 1%, 16 % and 30% (P <  0.001) in the groups with no, mild and heavy proteinuria, respectively.

Conclusions: We observed a high prevalence of proteinuria in patients with severe burns (>30% TBSA). Severely burned patients with proteinuria had a high risk of developing AKI and a poor prognosis for survival. This suggests that proteinuria should be used as a biomarker for identifying burn patients at risk of developing AKI.

Background: Ambulance services in Saudi Arabia are organised through the Red Crescent, the organisation that is responsible for ensuring adequate ambulance service for all communities in Riyadh. Paramedics are the first responders among the healthcare providers responsible for saving patients' live outside hospital settings. Work-related stress is a serious problem that affects the health and well-being of employees as well as the productivity of organisations. Stress has a huge impact on the performance and productivity of emergency health workers.

Objective: To explored the factors associated with stress and identified the effects of stress and burnout on Red Crescent ambulance workers.

Methods: This study explored the factors associated with stress and identified the effects of stress and burnout on Red Crescent ambulance workers. A cross-sectional study was conducted among ambulance workers at Saudi Red Crescent centers across four regions of the Ar-Riyadh province of Saudi Arabia. Questions about sociodemographic information, working conditions, level of burnout, and job stress were included in the questionnaires.

Results: Study sample responses regarding personal burnout level. The arithmetic mean, standard deviation, frequencies, and the responses (in %) to statements describing the personal burnout level are shown in Table 14.

Conclusion: Stress level and work-related burnout was a leading cause of poor performance and resulted in the inability of employees to perform assigned tasks.

Background/aims: Prognosis for patients with cirrhosis admitted to medical intensive care unit (MICU) is poor. The objective of this study was to assess the predictors for hospital mortality and admission of cirrhotic patients to MICU in Qatar.

Materials and methods: We conducted a retrospective cohort study of consecutive adult cirrhotic medical-ICU patients whom hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar. We compared them to cirrhotic patients who admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis.

Results: The cohort comprised 109 cirrhotic MICU patients, 86.2% were males and their mean age ± SD = 51.6 ± 11.5. MICU-cirrhotic had longer hospital length of stay (LoS) than medical wards-cirrhotic (both for survivors and non-survivors). Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p = 0.001). In multivariate logistic regression analyses, older age >60 years (p = 0.04), APATCH-II score (p = 0.001) and MELD score (p = 0.02) were independent predicting factors for overall mortality. Furthermore, admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score were independent predicting factors for MICU admission.

Conclusion: Severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APATCH-II score and MELD score predict mortality.

Introduction: Use of ECMO has been shown to be an acceptable intervention for patients with respiratory failure refractory to optimal ventilator management. As experience with ECMO grows the indications for its use are also expanding.

Case: Our patient is a 20-year-old female who was found lying on the roadside after being hit by a moving vehicle. She was rushed into the trauma room where she was intubated for low Glasgow coma scale, CT head, chest, abdomen and pelvis showed severe head injury with possible diffuse axonal injury, blunt chest injury, blunt abdominal injury with splenic injury was admitted under the care of TICU, repeat CT head showed multiple hemorrhagic contusions. Ventriculostomy with ICP monitoring device was inserted. She was aggressively treated for severe brain injury by neuroprotective interventions. Over following days had severe ARDS. Despite appropriate antibiotic therapy, lung protective ventilation, HFOV, patient had severe hypoxemia. Patient was evaluated for ECMO despite her severe neurological injury with ICH, possible poor neurological recovery. After discussions involving primary team, ECMO was considered initiated using femoral-Jugular cannulation. No systemic anticoagulation was used. Tracheostomy was placed and was weaned off ECMO over next week. ECMO decannulation was performed on 7th day. Patient had multiple interventions by the orthopaedic, weaned off decannulation in 18 days and tracheostomy was closed. Patient had neurological recovery was discharged to the rehabilitation.

Discussion: ECMO is an established salvage therapy for profound respiratory failure and the need for systemic anticoagulation has often contraindicated its use in patients with severe intracranial pathology, and in particular, recent hemorrhage like our patient. Advances in circuit and oxygenator technology have challenged this concern and cases of ECMO support with intracranial pathology have been recently described. Risks and benefits of systemic anticoagulation need to be considered during ECMO support.

Conclusions: Extracorporeal membrane oxygenation is an acceptable therapy for patients with profound respiratory failure secondary to trauma and intracranial pathology contraindicating the use of systemic anticoagulation.

Background: Anticipating falls in the Emergency Department is a very challenging task as it's often the most unpredictable setting. Fall risk assessment tools used in inpatient units do not adequately capture the risk factors present in patients presenting to the Emergency Department. The MORSE scale is implemented only at a latter phase of patient admission to the inpatient unit. The purpose of this study is to develop and implement a simple, fast and effective tool to identify the risk of fall at the triage.

Methods: We designed a tool to identify patients at risk of fall. We planned to randomly assign 200 patients equally in to the test and control arm. We created the Fall Risk Assessment Tool specifically for the use in the Emergency Department. The study was conducted at Hamad General Hospital, Emergency Department triage area. If a patient was identified as at risk for fall, a Fall risk sticker was pasted on top of the ED paper to indicate the risk. Any patient identified as at risk was re-evaluated throughout their stay in the Emergency Department.

Results: Hundred patients identified as at risk for fall at the initial triage were re-evaluated for fall risk using standard MORSE scale. Reassessment showed 67% of the cases identified at the initial triage come under high risk category using Morse scale, 31% had moderate risk and only 2% had low risk. There were no reported cases of fall. Hundred patients, excluded as low risk for fall at the initial triage were re-evaluated for risk for fall using the standard Morse Scale. Reassessment showed 98% of the excluded patient's came in the low risk category and 2% had moderate risk as per the MORSE scale.

Conclusion: Our tool was as safe as and effective in predicting falls as the MORSE Scale.

The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is an emerging infection that causes severe illness in patients, particularly those with comorbidities; and has a high mortality rate. Healthcare associated outbreaks have been reported across the Gulf region and the Republic of Korea. While there have been cases of MERS-CoV in Qatar, no healthcare associated outbreaks have been reported. The aim of this paper is to give a description of the infection prevention and control protocol implemented by the Primary Health Care Corporation to manage suspected or probable cases of MERS-CoV in the primary health care setting. This paper focuses on Alshahania Health Centre which is considered to be a high risk area due to its proximity to the camel shelter and race track. In order to gain an understanding of how patients visiting the health center are managed. Data was collected through a visit to the Alshahania Health Centre which included discussions with staff and documentation review. Our findings show that the infection control protocol implemented at Alshahania Health Centre is very robust and ensures that staff has clearly defined responsibilities in the management of a suspected case of MERS-CoV. A dedicated Isolation Team ensures a timely risk assessment is carried out which then triggers actions that reduce the risk of exposure to both patients and staff. The experience at Alshahania Health Centre also demonstrates that good communication and leadership are important factors in order to successfully embed infection control in clinical practice and prevent healthcare associated outbreaks of MERS-CoV.

Introduction: Despite the potential benefits of EMR systems to improve patient care, many attempts at implementing them have failed or met with high levels of user resistance, Implementations that failed have often been those with which the users were dissatisfied with the system.

Aim: The aim of this study is to assess the satisfaction of both the physicians and nurses with the newly introduced EMR system at the Emergency Department of Al Wakra Hospital, to find out if there was a significant difference between physician and nurse's perception to the system. And to determine which of the individual attributes of EMR were related to physician and nurse satisfaction.

Methods: Study design: cross sectional survey four month after of the introduction of the EMR system (Cerner) we surveyed 40 physicians and 96 nurses at the Emergency Department of Al Wakra Hospital. The questionnaire assessed: perceptions regarding EMR ease of use; concerns about impact upon work, and quality of patient care.

Results: The total satisfaction rate was 88.2%. 72.5% among the physicians and 94.5% among the nurses, both physicians and nurses were satisfied with the ease of use of the system, they find it generally to have a positive impact on their work, however both didn't find it to have an impact in reducing ED overcrowding.

Conclusion: Both physicians and nurses were satisfied with the EMR system.

Background: Non-adherence to antimicrobial guidelines is a major factor leading to emergence of antimicrobial drug resistance.

Objective: This study was carried out to investigate the adherence to local antimicrobial guidelines in the Emergency Department (ED) at Al Wakra Hospital in the state of Qatar.

Materials and methods: This cross-sectional, retrospective study was carried out in the Emergency Department of Al Wakra Hospital in Qatar. Prescriptions of 219 patients were investigated to study the adherence to antimicrobial guidelines. The relation of sex, age and emergency unit type to antimicrobial adherence as well as the appropriateness of antimicrobial prescribed on discharge were also evaluated.

Results: Overall adherence and non-adherence to local antimicrobial guidelines was found to be 41% and 59% of prescriptions respectively (P-value = 0.007). Participants had mean age of 42 ± 15.5. More adherence to guidelines was found among female patients and in critical care units. Furthermore, antimicrobial prescribed to patients on discharge was found to be appropriate in 60% of patients (P-value = 0.04).

Conclusion: Education of physicians and additional studies should be conducted in order to further investigate and improve adherence to antimicrobial guidelines.

Hospitals' track-and-trigger systems to identify and respond efficiently to patient's deterioration became an evidence base tool for patient safety and medical management worldwide. A prospective study about the Impact of Rapid Response Team Implementation in the Cuban Hospital was developed since September 2014 up to September 2015. The patients admitted in medical and surgical wards were screened upon admission and rescreened during every shift by nurses using the National Early Warning Score (NEWS), a multidisciplinary medical response team was designed and proper actions were done according to the acuity of illnesses and patient needs. The 100% of patients admitted were screened and properly followed during every shift, the system gave us the possibility for early detection of all the patients deteriorated, 9.9% in total, the 3.6% of patients admitted were transferred to ICU in deteriorated condition, decreasing to 0 the code blue activation and the unexpected mortality in wards. Early recognition and timely and competent clinical response gave us the opportunity to be proactive to protect our patients against life threatening situations. We recommend extend this result to all the hospital service using a wider system to include maternity and pediatric population, the implementation of the Qatar Early Warning System (QEWS) will be our next step to protect all the patients admitted in our Hospital.

Background: In 2011, HMCAS designed new Evidence-Based CPG. The previous protocols were not fit for purpose and not best practice. The service had multiple tiers of clinical practice among staff without standardization of care. CPG development is a knowledge management process to ensure standardization of care and a safer patient experience. This research sets out learning from two rounds of CPG development over 4 years.

Methods: The guidelines development process was mapped prior to starting in January 2015. CPG development and implementation went through 5 steps: 1. Scoping the guidelines: defining the purpose, the scope of service, and the end users of the guidelines. We conducted a staff survey to understand their views on presentation and purpose. 2. Establishing a working group to identify specific guidelines, clinical outcomes desired, and develop a writing template. 3. Conducting evidence reviews to draft the guidelines and then consulting with all role players to ensure guidelines are best practice and practical, and aligned to clinical pathways. 4. Guidelines publication considering ease of use, clarity, and balance between details and practicality. Finally, guidelines approval. 5. Guidelines implementation: Identifying champions to action alignment to systems (logistics/governance/management) and to redesign the corresponding educational curriculum.

Results: The development and implementation of the guidelines has resulted in significant changes within the Ambulance Service over 4 years. Reducing multiple tiers of care down to two tiers, standardized education of 900 existing and new clinical staff around guidelines, implementation of standardized pre-packed equipment within the ambulances, and standardized care to the community. This project was recognized by the MD's Stars of Excellence award 2013.

Conclusions: To implement standardized care and EBM, CPG are required. Guidelines development and implementation needs expertise, collaborative development, and champions who will undertake deliberate alignment of service activities and education to the guidelines.

Background: Hip fractures are very common in UK population (excluding Scotland) accounting for 64102 hospital admissions in 2014. FCIB is part of a best practice tariff and a quality indicator audited annually by the National Hip Fracture Database in UK, as part of NICE clinical guidelines. The ED protocol for fracture neck of femur (NOF) includes fascia Iliaca compartment block (FICB), which is a new service development as part of treatment.

Study objectives: To assess whether all patients with NOF were getting FICB prior to transfer from ED and to asses if FICB gave adequate pain relief.

Methods: A retrospective study new service evaluation was carried out on 58 patients admitted to orthopaedic ward from the ED with a diagnosis of fracture NOF. Exclusion criteria was contraindication to compartment blocks. This study focussed on the care received by the patients in the ED during the period from October 2014 to March 2015. A data collection spread sheet was developed with parameters based on the NICE guidelines, RCEM guidelines and the trust policy for performing FICB.

Results: Of the 58 cases, 51.72% of these received FICB and were documented. Of these 63.3% of patients had FICB performed within 4 hours of arrival to ED. The other 49% lacked evidence for FICB, assumed it was not done. Post-block pain scores were poorly documented. 82% of the blocks were performed by non-consultant doctors. One case of block failure and side effect.

Conclusion: This new service benefited patients with hip fracture, however has issues relating to compliance and consistency of service delivery and all efforts should be made to improve these.

Background: Spontaneous rupture of the renal pelvis is very rare and hence diagnosis may be delayed. Diagnosis of the rupture is best evaluated by CT and treatment is primarily removal of the underlying cause, followed by conservative management.

Presentation: An otherwise healthy 31-year-old male suffered abdominal pains and vomiting. His pain was at the right iliac fossa and suprapubic areas, which he rated as 7/10(NRS). He also reported dysuria of 2 days but with no other associated symptoms. On examination, Patient was vitally stable. On palpating his abdomen, there was right iliac fossa tenderness but no rebound tenderness, guarding nor rigidity, and the remainder of the examination was unremarkable. He received repeated analgesics; IV acetaminophen 1 g, 4 doses of IV fentanyl and in view of persistent pain and 2 additional doses of IV morphine. Abdominal ultrasonography were suggestive of distal right ureteric stone measuring 6 mm in diameter and mildly dilated upper and lower calyces with mild perinephric fluid. Along with, Tubular non-compressible structure 9 mm in diameter seen in RIF surrounded by minimal amount of fluid, giving an impression of query acute appendicitis with right distal ureteric stone. CT abdomen with double contrast revealed no features of acute appendicitis. However, there was a 4 mm stone in the lower end of the right ureter causing obstruction. Delayed series films showed rupture of the renal pelvis.

Conclusion: Rupture of renal calyx should be considered as one of the differential diagnosis for an unusual acute abdomen, not responsive to analgesics.

Background: Increasing levels of physical inactivity is associated with growing trends of childhood obesity as evidence suggests today's children physically inactive and unfit. The study aims to assess the effect of socio-demographic and lifestyle factors on mode of travel in school-aged children (10–15 years).

Methods: 4,497 school-aged children were selected from wave-1 of Understanding Society database in a multi-stage random sample with 81.8% response rate. Cross-sectional design was used to examine the relationship between active travel with demographic and lifestyle factors.

Results: Univariate analysis showed significant relation of age, region, smoking and eating fast food to the active commuter school-children. Multivariate adjusted analyses shows that children of ages 13 to 15 years were more likely to travel actively compared to those aged 10 to 12 years (OR = 1.92, 95%CI:1.65-2.23). Those engaged in sporting activity 3 times or more per week were more likely to be active travel compared to those less than twice per week (OR = 1.21, 95%CI:1.02-1.43). Children eating fast food once or less than per week were more likely to travel actively compared to unhealthy eaters. Most children living in their respective regions were less likely to travel actively.

Discussion: The positive association between active mode of travel and elder school children (13–15 years), who perform sport activities three times or greater per week and eating fast food once or less per week with active travel, reflect their free choice of mode of travel. Children who practiced sport more than three times per week and who ate less fast food showed healthy behaviors.

Introduction: Simulation is almost synonymous with computerised mannequins although they are not always essential components of the learning experience as what often matters most is the facilitation process of the learning experience rather than the technology.

Methods: We developed Visually Enhanced Mental Simulation (VEMS) for staff to demonstrate cognitive and decision making skills away from the practical context. Scenario participants are oriented by facilitators to the VEMS process which is a simulation approach that involves a whiteboard, laminated cards, and a poster to represent equipment and the patient. It requires participants to verbalise thoughts and actions including equipment settings, and actual communication with the patient and bystanders represented by the facilitators. Information like physiological parameters and interventions made by the participating crew are written on the whiteboard. Scenarios use the same scripts as what is prepared for full-scale simulation and are followed by a debriefing. It is complemented by parallel skills sessions, and ultimately both aspects are combined into full-scale scenario-based simulation.

Results: VEMS has been facilitated with uni/multi-professional teams of healthcare professionals for pre-hospital, interfacility, and handover scenarios. Comparison between VEMS and mannequin-based scenarios is ongoing and currently shows just a slightly less positive rating for VEMS although they advocate for this modality prior to full-scale simulation. VEMS reduces pressure on equipment demand and the staff engagement is such that similar clinical practitioner's mistakes are “observed” in both types of simulation approaches.

Conclusion: VEMS can be run almost anywhere as it requires a minimum of equipment but still requires time and experienced facilitators. Briefing about the process and expectations are as important as the preparation of the scenario script and clinical knowledge and facilitation style of the facilitators. VEMS can be very engaging for multiprofessional teams and address learning outcomes similar to what would be achieved in full-scale simulation.

Background: “Orientation” is an important phase when joining a new institution. It is the period when someone builds an understanding of their role/responsibilities in a new setting, and for colleagues to gauge someone's level of knowledge and competence. HMCAS recruits mostly overseas nursing qualified staff with variable experience and transforms them into Ambulance Paramedics (AP) all providing the same level of care in accordance to our Clinical Practice Guidelines.

Methods: Skills assessment using a 17–20 stations Objective Structured Clinical Examination (OSCE) process was introduced in the Training Department during a week-long instructor development workshop in 2013. Instructors were coached to develop practical/theoretical OSCE stations and took part in pilot sessions as examiners with new APs. The OSCE is now a core AP training programme component with weekly sessions to assess new staff on what they have been taught up to that point in time.

Results: Over 120 OSCE sessions have occurred in 2 years exposing about 600 staff to a minimum of 3 sessions each. A bank of over 40 stations has been developed and validated, and a team of trained examiners is used. As determined by the course evaluation form, although seen as a stressful experience, instructors and staff find it a very beneficial and effective assessment modality to prepare them for clinical practice. It motivates staff to study and they even request to have an OSCE per year as part of their continuing professional development.

Conclusion: We are committed and have processes in place to sustain the facilitation of OSCE sessions as it is a very practical way of assessing a wide range of skills over a set time period and gauging staff progress through consecutive sessions. The initial preparation is time consuming but we encourage other departments to explore this approach as part of their orientation/training programme.

Background: Whilst Head CT scanning carries an important role in the identification of clinically significant intracranial injuries, there are associated risks of radiation. Our initial audit of clinical notes and survey of EM physicians revealed a rate of 45% CT scans for pediatric minor head injuries with around half of requests not indicated. In 36% there were issues with documentation. The aim is to achieve a sustained compliance with Internationally acceptable guidelines of Head CT scanning for pediatric minor head trauma at Hamad General Hospital Emergency Department (ED).

Intervention: We conducted staff education through weekly program of Continuing Medical Education for emergency physicians, prominent display and availability of handouts of the International clinical decision rules (NICE guidelines, PECARN) in all clinical areas within the ED, encourage proper documentation for all head injury cases to meet JCI standards of documentation, and formulate a revised pediatric head injury guideline based on the international clinical decision rules.

Methods and results: The audit in August 2014 showed that 62 CT head were done, 45% of them were deemed unnecessary when measured against NICE guidelines. Also there was deficient documentation in 36% of cases due to the unavailability and difficulty accessing the guidelines. We supplied all areas in the ED with handouts of the guidelines, and conducted shop floor education for ED physicians. Regular sessions were conducted during educational activities and emergency seminars. The re-audit in January 2015 showed decreasing rate of CT scans at the rate of 22% achieving a reduction by 33% and improvement in the documentation by 31%. The overall reduction of and decreasing the percentage of unindicated CT head by around 30%.

Conclusion and recommendation: Managing minor head injury in pediatric age group becomes more safe by increasing the physician awareness about the evidence based updated guidelines.

Objective: The objective of this study was to collect feedback from Ambulance Paramedics (AP) with respect of their experience of using an External Chest Compression Device (ECCD) on cardiac arrest patients. Aspects of particular interest were ease of use and their perceived effectiveness of delivered CPR.

Background: HMCAS crews attend to several hundreds of cardiac arrests a year. To achieve Return of Spontaneous Circulation (ROSC), the key requirements are the provision of effective chest compressions delivering oxygen to the brain, maintaining coronary perfusion pressure, and priming the heart for successful defibrillation. Providing effective manual chest compressions in the austere Qatar pre-hospital setting with high temperatures is challenging, hence all HMCAS emergency vehicles have been equipped with ECCD.

Methods: HMCAS receives daily reports compiled by its Documentation Officers. These reports highlight specific cases in which use of the ECCD was indicated but not implemented. These cases are followed up and audited to assess if non-provision of automated chest compressions was clinically acceptable. HMCAS monitors specific key performance indicators, i.e. ’Use of the LUCAS™2 in Adult Medical CPR Cases’ as well as ’ROSC in Medical CPR’. Feedback was collected over a 3-month period using a 10-point Likert scale type questionnaire distributed to ambulance paramedic teams who had used the ECCD during a real medical cardiac arrest case.

Results: The results are based on 54 returned feedback questionnaires. Using a scale with 1 being very difficult and 10 being very easy, ambulance paramedics’ mean rating of the device's ease of use was of 8.8/10. Similarly, on a scale indicating perceived effectiveness, staff indicated that they found the chest compressions provided by ECCD to be highly effective (mean = 9.41/10).

Conclusion: HMCAS staffs are highly satisfied with making use of the device since it provides them with a safer work environment and they are less fatigued after finishing a CPR case, especially during the summer months.

Background: Breast cancer is the most common malignancy and leading cause of cancer mortality among females in Gaza. Most cases are diagnosed at late stage. Survival rates are persistently low in contrast to improved rates worldwide. Our study examined awareness, knowledge, attitude, practice and access to breast healthcare among both health professionals and women in Gaza.

Methods: In May and June 2014, using convenience and representative sampling, 100 health professionals from medical, surgical and obstetrics-gynecology completed a survey on basic knowledge of breast cancer, attitudes and practices. Structured interviews were conducted with 100 women 30 years and older across all districts and socioeconomic backgrounds. Women were interviewed about basic knowledge of breast cancer, self-exam, attitude and practice when a breast problem encountered, access, and barriers. Data was analyzed using excel to find frequency distributions.

Results: The health professional surveys showed: Only 15% offer breast exam to their patients, 13% believe mammography can cause cancer, 48% do not know that radiotherapy is not available in Gaza, 4% believe cancer breast is contagious. Health professionals expressed the need for standardized protocols and guidelines. Only 25% of surveyed women reported practice of self-examination, 87% had never had a mammogram or had been offered a breast exam, 26% think mammogram can cause cancer. However 80% were positive about seeking healthcare when needed. Most women accepted screening if affordable and were interested in receiving information about breast care.

Conclusion: Knowledge gaps in breast healthcare exist among healthcare professionals and women in Gaza strip. Awareness sessions, capacity building and specialized training of healthcare professionals are needed to improve quality of breast healthcare in Gaza. Increasing utility of mammography among women with access to multidisciplinary breast care may improve survival rate, particularly because most women in Gaza are keen on seeking medical care when needed.

Background: Intraosseous (IO) access are being widely used in resuscitation of patients with difficult intra-venous (IV) access. The United Kingdom Resuscitation Council guidelines recommend the use of IO access, after two minutes of failed IV access in adult patients or two failed IV attempts in pediatric patients. There are various complications associated with IO access such as extravasation of the infusion fluid or medications, bleeding, infection and pain1. Compartment syndrome is a rare complication associated with IO access. This is reported commonly in children where in certain cases the affected limb required amputation. We report a case where an adult patient developed compartment syndrome secondary to IO access.

Methods: A 52-year-old lady who was on dialysis for renal failure presented to the Emergency Department (ED) with septic shock. She was in peri-arrest and had a difficult IV access. Therefore an IO needle was inserted to her right tibia and resuscitation was carried out with fluids and medications. She required emergency intubation and ventilation and was later admitted to the Intensive Care Unit (ICU). The following day, it was found that she developed a compartment syndrome of the right lower leg where she had the IO access.

Results: Patient was taken to the theatre for an urgent fasciotomy of the affected leg by the orthopedic surgeons with input from plastic surgeons. She made a steady but full recovery and was discharged home later.

Conclusions: Compartment syndrome is a rare complication of IO access (0.6%) 1. Careful monitoring of the IO site is recommended. It is advisable to remove the IO needle once a definitive IV access is established.

1. Complication with Intraosseous Access: Scandinavian Users' Experience. Hallas et al. West J Emerg Med. 2013 Sep; 14(5): 440–443.

Background: Vaccine preventable diseases continue to kill large numbers of young children each year UNICEF estimates that 1.2 million deaths to children under five years of age could be prevented at low cost by vaccinating children. For example, it is estimated that measles related deaths have been reduced from about 2.5 million per year in 1980 to less than one million in 1990 (2)-a decline of more than 60 percent during the decade of the 1980s.

Purpose: Vaccinations are one of the most cost effective means to reduce morbidity and mortality associated with infectious diseases. The introduction of the vaccine has led to nearly a 90–100 percent reduction in target disease morbidity and mortality.

Methods: The information was collected used adopted WHO cluster survey 210 children to satisfy the research objectives_30 clusters with respondent in each were randomly chosen.

Findings: The result obtained showed that: Percentage of coverage with the BCG the number of vaccinated children by card (143) and from memory (12) with total percentage 74% and non-immunized (55) 26% for Penta3 and OPV3 the coverage was (57%) and the PCV3 coverage was (71%). The major reasons for non-immunization were unawareness of need for immunization or not able to return back to the second or third doses because of long distance and finance constrain. The study recommended that Strengthen social mobilization to increase routine immunization coverage and screening of defaulter children during the campaigns besides spending more efforts to decrease the dropout rate.

Conclusion: Darfur conflict during last decade, leads to massive population movement (nomads – refugees) that can threat the coverage all targeted children and reach every area but EPI in Sudan do effort to cover all population during campaign and routine immunization.

Introduction: The mechanism for carbamate toxicity is reversible cholinesterase inhibition, which leads to accumulation of acetylcholine at the neuromuscular junction.1 The cardiac manifestations of carbamate toxicity are rare. We report a case of carbamate toxicity with atrial fibrillation as the cardiac manifestation.

Case presentation: A 28-year-old patient, previously healthy, presented to the ED complaining of diplopia, dizziness, palpitation, and one episode of vomiting. The symptoms began two hours before when he was spraying pesticide at a farm. According to the patient he sprayed 9 liters of pesticide over a short period of two hours. The patient was not using any personal protective equipment. The pesticide used was later identified as Lannate, which contain Methomyl (carbamate). On examination, a chemical odor was noted. His initial vital signs were normal except heart rate of 134/min. The patient was decontaminated in the decontamination room to avoid further exposure. He had constricted pupils of 2 mm. There were no other signs of organophosphate or carbamate toxicity. His initial ECG showed atrial fibrillation (AF) with fast ventricular response rate. The pseudo-cholinesterase level was. The toxicology service was consulted, and they advised not to start antidote treatment only for the AF, as other signs and symptoms were absent. The cardiology on call assessed the patient and started amiodarone infusion presuming new onset of AF. The patient's rhythm reverted back to sinus 12-hour post-presentation. He was discharged next day with a diagnosis of paroxysmal AF secondary to carbamate poisoning.

Discussion: AF in carbamate toxicity is rare and only few cases have been reported in the literature.2,3 It is postulated that, enhanced nicotinic activity stimulates postganglionic sympathetic terminals and produces a dramatic release of norepinephrine.4 Norepinephrine mediates its arrhythmogenic effects by increasing automaticity of cardiac cells and by decreasing the cardiac muscle fibrillatory threshold.5

Backgrounds: Infection with Neisseria meningitides can produce a variety of clinical manifestations. Mortality and long-term morbidity can be very high in patients with invasive meningococcal disease if the infection is not treated appropriately. Our main objective was to evaluate mortality of all children admitted with acute meningococcal septicaemia (AMS).

Methods: We conducted a retrospective study of all paediatric-cases of acute meningococcal septicaemia admitted to Al-Nasser Paediatric Hospital, the largest paediatric hospital in Gaza Strip, between January-2009 and September-2015. All AMS cases were diagnosed based on the clinical presentation, skin smear and blood culture. Outcome measures were predicted mortality using Paediatric Risk of Mortality score III (PRISM III), actual mortality and standardised mortality ratio.

Results: A total of 240-children were admitted with proven AMS. Aged range from 1-month to 12-years, and 113 of them (47%) were male. The number of admitted children with AMS was decreased from 47–59 cases/year in the 2009–2011 period to 21–22 cases/year in the 2012-201. The total mortality predicted by PRISM III was 25.56%, however the actual overall mortality was 49 children (20.8%): 16(48.5%) aged less than-a-year, 17(22.1%) 1–3 year-old, 9(18.8%) 3–5 year-old and 7(8.5%) 5–12 year-old (p value = 0.00299). Standardised mortality ratio was 0.814. Forty-one children (82%) were died within the first 24-hours of admission. Sixty-nine (28.8%) children received corticosteroid, 85(35.4%) received inotropic medications and 46(19.2%) required mechanical ventilation for a median of 24-hours. In 75(31.3%) children, AMS was associated with meningitis. Multi-organ failure (n = 22, 9.2%) was the most common complication, followed by skin necrosis (n = 13, 5.4%), convulsions (n = 13, 5.4%), and disseminated intravascular coagulopathy (n = 10, 4.2%).

Interpretation: The mortality rate of the disease still high, however, this can be explained by the high predicted score of mortality, which reflect the severity of admitted cases. The mortality was significantly associated with younger age-group. New model of treatment (e.g. plasmapheresis) may be useful in decreasing mortality.

Background: Qatar is about to host the 2022 FIFA World Cup-WC, this can stress the public health system and resources of Qatar as hosting country. Reducing public health risks and ensuring people's safety at The Qatar 2022WC requires thorough planning and coordination. The aim is to obtain a comprehensive insight into the available practices concerning the infectious diseases preparedness and response for major Sporting events and to advise Qatar W.C-2022 health committee accordingly.

Methods: A desk review of WHO literature in public health considerations during mass gatherings was done, with particular focus on the Communicable Disease alert and response for mass gatherings.

Results: The literature suggests certain critical factors and preconditions for success that are common to most events as well as strategic, organizational, and tactical lessons learned that can be applied for Qatar WC 2022 includes, Comprehensive risk assessment should be conducted before the event, this will allows planners in Qatar to reduce the risk of communicable disease outbreaks associated with WC2022. Plans for risk management and risk communication need to be developed. New surveillance system should be in place for a sufficient length of time prior to the WC and this surveillance need to be divided into three phases, Pre-WC surveillance, WC-based surveillance and Post-WC surveillance.

Conclusion: The challenge for Qatar is to recognize the possible benefits from the outset of planning for the coming 2022WC and to build a positive and Strategic approach to communicable diseases issues into the earliest stages.

Background: The HGH Microbiology lab indicator showed that our blood culture contamination rate has been consistently higher than the international benchmark thereby we aim to reduce it in the critical area of Emergency Department by 50% by the end of July 2015 and at least 90% by end of February 2016.

Methods: A pilot area was chosen in the Emergency Department to do a study for 44 weeks after which blood culture kits (previously trolleys & trays were used) containing sterile gloves, masks, and blood culture supplies were introduced into the Critical area of ED-HGH in August 2015. Training included- new instructions to have two staff members present when drawing blood cultures (preceptor-preceptee methodology) thereby prohibiting drawing blood cultures from pre-existing lines and proper follow-up of every step. False positive blood culture rates were measured in the weeks preceding and the weeks following, this intervention.

Results: In the 8 weeks following the intervention, the average false positive blood culture contamination rate in HGH ED reached 1.9% (which was the benchmark) out of 318 blood culture samples. In the 6 months preceding, the blood culture contamination rates ranged from 4% to 1.5% each month.

Conclusions: Blood culture kits and educational training on proper technique resulted in significant reduction (>60%) in the false positive blood culture rate in the Critical areas of ED-HGH. Studies at other institutions have suggested that reducing the false positive blood culture rate could decrease costs by preventing unnecessary hospitalizations and administration of unnecessary antibiotics, as well as helping to prevent the development of multi-drug resistant organisms. 0000-0003-0866-6512 0000-0002-1057-2438.

To assess if stratification of patients based on clinical severity, laboratory markers and radiological findings at presentation would enable better prediction for the need for a surgical intervention. Single-centre retrospective cohort study done in the in-patient pediatric wards of a tertiary care centre in the State of Qatar. Participants – 56 children (aged 6 months – 14 years) with empyema or parapneumonic effusion, from July 2009- June 2013. Patients were classified into mild and severe clinical presentation based on the 2011 British thoracic society (BTS) pneumonia guidelines. Interventions were categorized as conservative (antibiotics only), non-conservative (antibiotic and surgical intervention). The values of CRP, ESR, WBC count, upon admission and follow up were also assessed, along with pleural fluid markers such as LDH, glucose and PH. The chest X-ray and chest USG were also assessed for severity and loculations. Of the 56 patients included, 29 (52%) had severe and 27 (48%) had mild clinical presentation. 26 patients (46.4%) were managed conservatively, while 30 patients (53.6%) required intervention. Younger patients (3.8 ± 3 years) tend to have increased risk for intervention, severe clinical presentation and loculations on USG. Age ≤  5 years, severe clinical presentation, serum WBC count ≥ 20,000/mm3, ESR ≥ 80 mm/hr, serum CRP ≥ 100 mg/dl, moderate to severe effusion on chest radiograph and presence of loculation on USG individually increased the likelihood for a surgical intervention in pediatric patients with parapneumonic effusion. Having ≥  4 out of 7 criteria accurately predicted a high risk for the need for surgical intervention (OR-6.93, 95%CI-1.2-37, p-0.023, sensitivity 72%, specificity 73%). Having ≥  4 out of 7 criteria accurately predicted a high risk for the need for surgical intervention. Prospective trials are recommended to see if this would enable homogeneity in deciding when to intervene in patients with parapneumonic effusion thereby reducing the LOS and cost-burden on the healthcare system.

Background: Approximately 1,000 U.S. citizens suffer from sudden cardiac arrest daily outside of the hospital setting. Providing cardiopulmonary resuscitation (CPR) improves survival if appropriately administered; however, many are resistant to initiate mouth to mouth. Hands only CPR (HOCPR) was developed by the American Heart Association to improve technique retention and increase the willingness to administer CPR.

Methods: Participants watched a teaching video from the American Heart Association, followed by a mannequin demonstration. Participants then filled out a survey immediately after practicing HOCPR on the mannequin and at one month.

Results: 75 Subjects received HOCPR training and completed a survey and 44 (59%) of the subjects completed a one month follow-up survey. The initial survey revealed that 100% (n = 75) were able to correctly recall the HOCPR process and 79% (n = 59) were very likely to provide HOCPR to a person suffering from a cardiac episode. 76% (n = 57) were more willing to assist a person in need as a result of not having to provide breathes to the person in need. At the one month follow-up, 100% (n = 59) of the respondents remembered the order of steps and 73% (n = 32) were willing to provide HOCPR since no rescue breathing was required. After learning the material, 15% (n = 11) of the participants tried to teach their family and friends about HOCPR.

Conclusion: HOCPR is a simple method which the average person is able to recall after a brief training in proper technique. Subjects were more willing to provide HOCPR and teach family and friends.

Introduction: Pakistan has seen repeated outbreaks of the disease over the past decade or so. In 2011 the largest outbreak was seen in Punjab where 20,864 cases were reported. This study was conducted to estimate the disease burden and analyze epidemiological trends using data from the provincial Dengue Surveillance System, Punjab.

Methods: A descriptive analysis of data from January 1 to December 31, 2013, was undertaken. A case of dengue fever was defined as any person with fever from 2–10 days with any three of the following symptoms: headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestation, leucopenia, abdominal pain and restlessness. Population estimates from Federal Bureau of Statistics were used to calculate attack rates.

Results: From January 1 to December 31, 2013, a total of 14,145 suspected cases were reported and 2,662 were confirmed. Out of cases 9,038 (69.3%) were males and 03 deaths were reported with CFR 0.11%. Mean age was 28.5 years (range 1–99 years). About 28 (0.2%) had previous history of dengue fever. Lahore was the most severely hit city (AR = 173/100,000) followed by Rawalpindi (AR = 52/100,000), Kasur (AR = 6.8/100,000) and Faisalabad (AR = 3.1/100,000). Most severely affected age group was 15–49 (AR = 30.8/100,000) followed by 50+ age group (AR = 15.5/100,000). Males were more affected (AR = 26.3/100,000) than females (AR = 11.8/100,000). The cases started increasing in August (1,128), peaking in November with 4,210 cases reported and then declining in December (758).

Conclusion: The analysis showed predominant involvement of adult males. Moreover highest number of cases was reported in the post-monsoon months of September through December. Age, gender specific health education and area specific larvae and vector control activities should be initiated. In 2014 there was significant decrease in dengue cases in Punjab and especially in Lahore where age and area specific targeted activities were conducted and AR was decreased to 21/100000.

Background: In April 2014, the South West London and Surrey Major Trauma Network entered its 4th year as an operational network, consisting of one Major Trauma Centre (MTC) and 7 acute Trauma Units (TUs) over a wide geographical area. In the year ending March 2014, 75% of the major trauma patients were taken to the MTC. However many patients with ISS >15 were admitted to TUs. Regular governance meetings are key to ensure these patients have received an appropriate level of care.

Case description: A service evaluation of care provided under governance framework, using the ISS as a guideline, was carried out. Patients who sustain traumatic injuries are managed in accordance with the Major Trauma Clinical Standards, the Trauma Audit and Research Network (TARN) measurable quality indicators and Trauma Quality Network System (TQuINS) recommendations. Available data indicates that there is a possibility that patients who present to a TU rather than a MTC may receive less than optimal care. In order to mitigate this difference it is necessary to have a governance system to ensure the patient care is optimal.

Methods: A proforma was developed for data collection with key trauma measures as quality indicators and the results collated in an Excel spreadsheet. A standard operating procedure and flow chart processes were developed to review major trauma cases. The TARN Office identified suitable patients and a multidisciplinary team reviewed the notes. Issues with care were formally registered with trust incident reporting system and registered in the trauma risk register. Findings were presented in the trust audit study day, in the Trust governance committee and disseminated for development.

Conclusions: Initiating a robust governance system and process will minimise substandard care and help standardise care across the network.

Background: Medical missions have become a part of the Global Health Programs at many academic institutions. Commonly these programs involve annual trips to locations in the United States and around the world. The University of Toledo Medical Center (UTMC) sought to develop a sustainable mission that has educational and clinical value to both the local community and academic institution.

Methods: The Department of Emergency Medicine at UTMC has worked with Salud Total, a small health clinic in La Ceiba, Honduras. Salud Total is staffed by a general practitioner, nurse and ancillary staff. During a mission the clinical volume increases over 100 patients a day. UTMC staff and senior ED residents see general medical complaints and perform small surgical procedures. Specialists, such as cardiologists and obstetricians see those needing specialty care. Education is provided in the form of bedside clinical teaching and materials distributed to staff and patients.

Results: This mission has provided clinical services to an underserved population, providing specialty medical care that otherwise was unavailable to these patients. Returning every 3 to 4 months allows the mission team to follow-up on treatment or procedures initiated on prior visits and provides the opportunity to advance clinical care through ongoing teaching and education.

Conclusions: Through our approach, we have enhanced clinical capabilities, increased the knowledge and skill set of the local practitioner as well as provided education to the patient and local community. Future expansion involves incorporation of telemedicine to provide real-time support for this clinic population and medical staff.

Introduction: Gallbladder volvulus is a rare entity, with a predilection for elderly women in their 7th or 8th decades of life. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Presence of redundant mesentery is a prerequisite. The disease is a frequent mimicker of acute cholecystitis, often difficult to diagnose preoperatively. Till date only about 300 cases have been reported in the literature, with children and adolescent presentations being exceedingly rare.

Case description: We report a case of an 18-year-old female who presented to emergency with right upper quadrant pain for a day associated with repeated vomiting. The patient was stable, had tenderness in right hypochondrium. Patient was evaluated as a potential case of acute cholecystitis. Laboratory investigations have shown normal white cell count, double normal liver function tests. Ultrasound showed that the gallbladder was out of the fossa with significant edema and wall thickness suggestive of gallbladder torsion. Further workup with MRCP was done, which showed retrohepatic gallbladder, with partial volvulus and hemorrhagic acalcular cholecystitis. The patient underwent laparoscopic detorsion and cholecystectomy and had an intraoperative evidence of gallbladder volvulus with gangrene with an uneventful course of hospital stay.

Conclusion: We believe that this may be the first documented case of this rare condition from Qatar. Gallbladder volvulus mostly occurs in elderly, but it might occur in young patients as well and should be included in differential diagnosis of abdominal pain. Ultrasound is a safe, feasible diagnostic tool, as sensitive as MRI in diagnosis of gallbladder volvulus.

Background/objective: Several inflammatory biomarkers of infection including procalcitonin (PCT) and C – reactive protein (CRP) have been shown to be useful in diagnosis of infection in different clinical settings. The purpose of this study was to determine the diagnostic value of serum PCT, CRP and White Blood Cells (WBC) as markers of sepsis in critically ill patients in Qatar.

Materials and methods: The PCT levels and other related inflammatory markers (CRP and WBC) were measured in 137 adult patients with a suspected diagnosis of sepsis and admitted to Internal Medicine inpatient service (i.e., Medical Wards and Medical Intensive Care Unit) at Hamad General Hospital, Hamad Medical Corporation-Qatar during the period from January 2011 to December 2013.

Results: The serum PCT was measured by chemoluminiscence immunoassay and the results were compared with other inflammatory markers between the patients with and without proven sepsis. A significantly higher PCT level was observed among patients with severe sepsis and septic shock compared to those without sepsis (19.34 ± 50 and 25.91 ± 61.3 vs. 4.72 ± 10, respectively; (p = 0.011). No significant differences were found in CRP and WBC between these groups. Non-survivors of both septic and non-septic groups had a mean PCT level of 22.48 ± 8.26 significantly higher than that measured in survivors of both groups (p = 0.01), a difference not evident in other inflammatory parameters.

Conclusion: PCT is a highly efficient inflammatory laboratory parameter for the diagnosis of severe sepsis and septic shock but WBC and CRP levels were of little value. PCT value assists in diagnosis of septic shock hence supporting appropriate disposition of patients. Levels of PCT also have prognostic implications with regards to mortality suggesting intensification of antibiotic therapy and supportive measures including appropriate family counseling.

Background: The last cholera epidemic in Sudan occurred in 2006/07, over 20,000 cases (4% case fatality rate) were recorded, index case was coming from South Sudan. In regard to recent outbreak in South Sudan June 2015, Sudan carried out preparedness procedures to prevent cholera spread. The uncontrollable open borders and the South Sudan refugees-over 198,000 – settled in Sudan poses a great cholera spread risk.

Objective: To illustrate cholera preparedness and response activities.

Methods: Comprehensive study utilize data collected from reports of cholera higher committee, investigation for cholera rumors, risk assessment missions for refugee camps and preparedness strengthening missions to States bordering South Sudan.

Findings: Higher committee was developed to undertake and follow preparedness activities under areas of surveillance, health promotion, environmental health, case management and points of entry (POE). Surveillance system was enhanced in all sentinel sites (1522) including refugee camps, daily zero reports were activated. Training for Rapid response teams and health cadres at hospital were achieved in all States with (70%) of the target. 39 rumors for cholera were investigated, laboratory test indicated negative results. Regarding case management; Cholera kits, protocols and leaflets were distributed to all States, isolation areas were established in Khartoum and bordering States. Preventative precautions at POE were implemented to rehabilitated isolation area at Khartoum airport and establish case referral system. Trips coming from South Sudan were observed throughout the period of the outbreak and leaflet distributed to passengers Actions were carried out urgently to allow chlorination of water in all States and provide deep trench latrines with 50% of target with focusing on refugee camps. Administration of cholera vaccine recommended by WHO assessment mission at refugee camps.

Conclusion: Significant government and partners commitment to avail resources was observed. Efforts done lead to reduce possibility of cholera spread especially at refugee camps.

Background: Multiple trauma patients are evaluated and managed by the Emergency Department (ED) in Al Wakra. The assessment, management, and disposition of this population have become a significant workload component. The aim of this study was to evaluate the trauma service at Al Wakra ED.

Methods: In our study, we aimed to collect data on the trauma patients, admitted between July 2014 and October 2015, who presented to the ED, at Al Wakra Hospital, and then transferred to the major trauma unit at Hamad General Hospital (HGH), Doha, if further subspecialty management was needed. The data analyzed was for demographic characteristics, triage categories, and need for transfer to the level one trauma center for further management.

Results: Total of 59 patients with multiple trauma were admitted to Al Wakra ED, with mean age of 28 ± 19 years. Of these 91% were male. Based on the trauma severity, majority of the cases were level 2 trauma (92.73%), while trauma level 1 and trauma level 3 were (5.45%) and (1.82%) respectively. The most frequent anatomical type was head trauma (62.71%) followed by extremities trauma (33.9%). Other types included chest trauma (23.73%), spinal trauma (18.64%) and abdominal trauma (15.25%). The most common consultation services requiring transfer to level trauma center at HGH, were the neurosurgery (59.32 %) followed by the orthopedics (33.9%). It was found that 61.2% of the patients were admitted. The mean length of stay (LOS) was 8.35 days, while the median LOS was 4 days.

Conclusions: The Emergency Department at Al Wakra Hospital was able to receive and do the initial stabilization of multi-trauma patients. However, lack of certain sub-specialties mainly neurosurgery required transfer of two thirds of the patients to level one trauma center for further management. This may point to the future need of implementing neurosurgery services at Al Wakra Hospital.

Background: Hepatitis C viral infection is a public health concern worldwide and a major cause of morbidity and mortality in several countries that supply the State of Qatar with many of its laborers. The objectives were to measure the prevalence of hepatitis C viral infection among single male laborers; detect the practices that may catalyze the spread of the infection; and assess the knowledge gap.

Methods: A cross-sectional study was conducted in 2014 and involved 504 expatriate single male laborers seeking health care in two Qatar Red Crescent health centers.

Results: Results showed that only 5% of the total participants have ever been tested for hepatitis C and positive serology was detected in 4 respondents (0.8%), three of them from Egypt and one from Nepal. Three out of the 4 positive cases did not know they were infected and 2.5% lived with someone harboring the infection. Respondents appeared to have varying healthcare needs with 57% subject to medical procedures outside Qatar. Various risk practices for hepatitis C infection were reported including ear/body piercing (21.9%), tattooing (13.3%), contact with blood (17.0%), sharing personal equipment (12.2%) and injecting with used needles or syringes (7.4%). Less than 40% of respondents had knowledge of all modes of hepatitis C transmission.

Conclusion: Further actions notably building HCV monitoring system, setting a prevention plan, building screening strategy were need to be complemented by a contract renewal or a 3-year screening policy.

Background: Hamad General Hospital (HGH) Emergency Department (ED) provided 465,942 patient visits in 2014. (ED) use has increased annually resulting in overcrowding, longer wait periods for service and increased stress on health care workers. Much attention has been paid to factors contributing to this increased usage such as the return visit of an (ED) patient within 48 hours of the initial visit. 48 hours is the benchmark time period used in measuring (ED) return visits utilized by many countries and it became a mandatory quality indicator of performance by the Supreme Council of Health in Qatar on April 2015. This study was conducted to identify factors associated with scheduled and unscheduled 48 hours return visits to serve as a basis for a Quality Improvement Project (QIP) for development of interventions to decrease unscheduled returns.

Methods: An exploratory quantitative study using a descriptive correlational design was performed. The sample consisted of all patients had a return visits to (ED) within 48 hours from the discharge time during January 2015 at the study facility. Data were abstracted from electronic patients’ records utilizing the data collection tool, all electronic records was reviewed by experienced emergency physicians.

Results: For the study month of January 2015 there were 1023 return visits within 48 hours from the discharge time (2%) out of 42981 (ED) patients. 906 visits (89%) was unplanned out of them 102 visits (11%) was clinically significant. 85 cases(9%) were admitted on the return visit and we had no mortality cases. Abdominal pain was the main presenting complaint (28%) of all revisits followed by musculoskeletal pain (13%) for patients whom presenting with the same complaint.

Conclusion: Abdominal pain is the most frequent complaint associated with unscheduled return visits. Further Study is important to design and implement interventions to decrease the frequency of unscheduled returns.

Background: Point-of-care ultrasound is an invaluable tool in the diagnosis and management of many conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures.

Objectives: This study aimed to investigate the current utilization of point of care ultrasound in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization.

Methods: A cross sectional survey of emergency physician's experience with ultrasound was conducted, examining training, exposure and barriers to use. This paper-based survey was completed by the participants in the presence of study authors to improve compliance. Data was collected over a period of two months, from October to November 2014.

Results: One hundred and five (105) physicians participated in the survey. Fifty-six physicians had prior training in ultrasonography from courses approved by The Royal College of Emergency Medicine in the United Kingdom, and The Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had undertaken other non-accredited ultrasound courses. All of them reported an improvement in their procedural skills by employing ultrasound. Perceived lack of time in the Emergency Department was the main barrier to scanning. Other hurdles included a deficiency of trained personnel for guidance, shortage of equipment and a lack of experience and interest. Hands on training were stated as the preferred method for enhancing ultrasonography skills.

Conclusions: There has been underutilization of point-of-care ultrasound by emergency physicians. Availability of dedicated time, equipment, supervision and training will help to increase its usage.

Background: The rate of patients who arrive at the Emergency Department (ED) but leave before being seen (LWBS) is considered an important marker of the quality of care.

Objectives: To evaluate the rate of LWBS at ED in Al Wakra Hospital (AWH) and to identify predictive factors associated with LWBS.

Methods: This was a retrospective study of patients who left the Emergency Department without being seen by physicians between January 1, 2015 and May 31, 2015. Factors associated with LWBS such as the age, sex, time of the day, day of the week, median ED waiting times and common ED presentation were analyzed.

Results: Out of 95,375 patient visits; there were 426 cases of LWBS over the 5-month period. The highest rate of LWBS was seen on the month of March. Independent factors associated with LWBS patients include patients who are middle age (19-43 years), female (56%), and patients being presented at non-critical areas (100%), night shift visits (46%), on weekend (52.8%). Musculoskeletal complaint was the most frequent complaint associated with LBWS (31%) and the median waiting time was 45 minutes among LBWS patients.

Conclusion: The rate of patients leaving without being seen at ED in AWH is very low. More investigations need to be conducted to improve LWBS rate during night and weekends.