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.

Head trauma is a high-risk presentation to the emergency department (ED). Preventing secondary brain injury through earlier diagnosis and intervention relies on timely access to head CT. Wexford General Hospital (WGH) ED uses NICE guidelines, which recommend specific timeframes for acquiring CT in head trauma. Following an audit demonstrating low compliance to NICE CG176 time standards in 2020 (34%), a quality improvement project was undertaken to optimize imaging pathways for head trauma.

94 head trauma CT scans were analyzed over a two-month period (June 14, 2022-August 14, 2022) from the NIMIS and IPMS databases to establish current time compliance and median wait times for CT.

Following the implementation of a head injury assessment proforma at triage to prompt earlier evaluation of high-risk head injuries, 108 head trauma CT’s were reviewed over a two-month period (August 15, 2022-October 15, 2022) to determine if these parameters improved.

Unpaired, two-tailed Mann-Whitney’s test was used to compare median wait times from triage to CT. Two-tailed Chi-square test was used to compare overall compliance rates.

Overall ED compliance to NICE time standards improved following implementation of the proforma (43% vs. 36%, p=0.401).

For CT scans that were indicated within one hour, there was a statistically significant decrease in median wait time from triage to CT (134mins vs. 186mins, p=0.046). There was also a decrease in median wait time for scans indicated within 8 hours; however, this did not reach the threshold for statistical significance (216mins vs. 275mins, p=0.230).

Although there was an overall reduction in wait times for CT, this did not translate to a significant improvement in compliance rates to NICE CG176 time standards. This suggests that, despite earlier identification of these high-risk head injuries at triage, other systemic barriers to obtaining head CT are present and warrant further investigation.

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.

The Health Information and Quality Authority (HIQA) Tallaght Report of 2012 found care of lodged admitted patients on ED trolleys was undermined in terms of quality and safety. HIQA advised the practice of lodging in ED adjacent hospital corridors should be discontinued entirely. This message was reiterated during the pandemic. Some lodged patients may spend the total duration of their admission on an ED trolley. ED has 15 Adult rooms, seven pediatric rooms, two minor injury rooms, one procedure room and two resus bays. The aim was to calculate the annual number of days when no admitted patients were lodged on trolleys in ED.

A descriptive study using data available from nationally issued reports on patients allocated to trolleys to the ED of Wexford General Hospital from January 2019-September 2022. Data was collected from national HSE daily SBAR reports. “Lodged patients” were those present in ED admitted but for whom no ward bed existed at 0745 daily.

Data was collected for 1,369 days, 90 days were excluded due to missing data sets, and data were included for 1,279 days. 290 days were recorded in 2019 with no lodged patients, 126 in 2020, 55 in 2021, and only 11 days in 2022 with no lodged patients. In 2022 the average number of lodged patients was six (Range 0-19). A total of 47 days had a lodged count of ten or greater.

Despite a strong recommendation from HIQA to terminate the practice of ED patient lodging, this has not been implemented. During the COVID-19 pandemic, there had been a reduction in the overall number of patients visiting the ED. This contributed to the reduction in trolley-lodged patients however post-COVID pandemic there has been a surge in attendance with a clear deficit in bed capacity.

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.

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.

The choice of terms used to describe ‘foods to limit’ (FTL) in food-based dietary guidelines (FBDG) can impact public understanding, policy translation and research applicability. The choice of terms in FBDG has been influenced by available science, values, beliefs and historical events. This study aimed to analyse the terms used and definitions given to FTL in FBDG around the world, including changes over time and regional differences.

A review of terms used to describe FTL and their definitions in all current and past FBDG for adults was conducted, using a search strategy informed by the FAO FBDG website. Data from 148 guidelines (96 countries) were extracted into a pre-defined table and terms were organised by the categories ‘nutrient-based’, ‘food examples’ or ‘processing-related’.

National FBDG from all world regions.

None.

Nutrient-based terms (e.g. high-fat foods) were the most frequently used type of term in both current and past dietary guidelines (91 %, 85 %, respectively). However, food examples (e.g. cakes) and processing-related terms (e.g. ultra-processed foods) have increased in use over the past 20 years and are now often used in conjunction with nutrient-based terms. Regional differences were only observed for processing-related terms.

Diverse, and often poorly defined, terms are used to describe FTL in FBDG. Policymakers should ensure that FTL terms have clear definitions and can be integrated with other disciplines and understood by consumers. This may facilitate the inclusion of the most contemporary and potentially impactful terminology in nutrition research and policies.

This study aimed to critically analyse Australia’s current and proposed policy actions to reduce added sugar consumption. Over-consumption of added sugar is a significant public health nutrition issue. The competing interests, values and beliefs among stakeholders mean they have disparate views regarding which policy actions are preferable to reduce added sugar consumption.

Semi-structured interviews using purposive, snowball sampling and policy mapping. Policy actions were classified by two frameworks: NOURISHING (e.g. behaviour change communication, food environment and food system) and the Orders of Change (e.g. first order: technical adjustments, second order: reforming the system, third order: transforming the system).

Australia.

Twenty-two stakeholders from the food industry, food regulation, government, public health groups and academia.

All proposed and existing policy actions targeted the food environment/behaviour change; most were assessed as first-order changes, and reductionist (nutrient specific) in nature. Influences on policy actions included industry power, stakeholder fragmentation, government ideology/political will and public pressure. Few stakeholders considered potential risks of policy actions, particularly of non-nutritive sweetener substitution or opportunity costs for other policies.

Most of Australia’s policy actions to reduce added sugar consumption are reductionist. Preferencing nutrient specific, first-order policy actions could reflect the influence of vested interests, a historically dominant reductionist orientation to nutrition science and policy, and the perceived difficulty of pursuing second- or third-order changes. Pursuing only first-order policy actions could lead to ‘regrettable’ substitutions and creates an opportunity cost for more comprehensive policy aimed at adjusting the broader food system.

Relapse and recurrence of depression are common, contributing to the overall burden of depression globally. Accurate prediction of relapse or recurrence while patients are well would allow the identification of high-risk individuals and may effectively guide the allocation of interventions to prevent relapse and recurrence.

To review prognostic models developed to predict the risk of relapse, recurrence, sustained remission, or recovery in adults with remitted major depressive disorder.

We searched the Cochrane Library (current issue); Ovid MEDLINE (1946 onwards); Ovid Embase (1980 onwards); Ovid PsycINFO (1806 onwards); and Web of Science (1900 onwards) up to May 2021. We included development and external validation studies of multivariable prognostic models. We assessed risk of bias of included studies using the Prediction model risk of bias assessment tool (PROBAST).

We identified 12 eligible prognostic model studies (11 unique prognostic models): 8 model development-only studies, 3 model development and external validation studies and 1 external validation-only study. Multiple estimates of performance measures were not available and meta-analysis was therefore not necessary. Eleven out of the 12 included studies were assessed as being at high overall risk of bias and none examined clinical utility.

Due to high risk of bias of the included studies, poor predictive performance and limited external validation of the models identified, presently available clinical prediction models for relapse and recurrence of depression are not yet sufficiently developed for deploying in clinical settings. There is a need for improved prognosis research in this clinical area and future studies should conform to best practice methodological and reporting guidelines.