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Article: Trauma-Related Clinical Practice Variation in Dutch Emergency Departments.

Tierie, Elise L / Barten, Dennis G / Esteve Cuevas, Laura M / Veugelers, Rebekka / Gaakeer, Menno I

2023 Volume 11, Issue 5

Abstract: Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative ...

Abstract	Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.
Language	English
Publishing date	2023-03-03
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2721009-1
ISSN	2227-9032
ISSN	2227-9032
DOI	10.3390/healthcare11050748
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Article ; Online: Crowding, perceived crowding and workload in Dutch emergency departments: should we continue on the same road?

Mol, Sander / Gaakeer, Menno I / van der Linden, M Christien / Baan-Kooman, E C Margré / Backus, Barbra E / de Ridder, Victor A

European journal of emergency medicine : official journal of the European Society for Emergency Medicine

2023 Volume 30, Issue 4, Page(s) 229–230

MeSH term(s)	Humans ; Workload ; Emergency Service, Hospital ; Crowding
Language	English
Publishing date	2023-04-28
Publishing country	England
Document type	Journal Article
ZDB-ID	1233544-7
ISSN	1473-5695 ; 0969-9546
ISSN (online)	1473-5695
ISSN	0969-9546
DOI	10.1097/MEJ.0000000000001034
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Article ; Online: Improving design choices in Delphi studies in medicine: the case of an exemplary physician multi-round panel study with 100% response.

Veugelers, Rebekka / Gaakeer, Menno I / Patka, Peter / Huijsman, Robbert

BMC medical research methodology

2020 Volume 20, Issue 1, Page(s) 156

Abstract: Background: A proper application of the Delphi technique is essential for obtaining valid research results. Medical researchers regularly use Delphi studies, but reports often lack detailed information on methodology and controlled feedback: in the ... ...

Abstract	Background: A proper application of the Delphi technique is essential for obtaining valid research results. Medical researchers regularly use Delphi studies, but reports often lack detailed information on methodology and controlled feedback: in the medical literature, papers focusing on Delphi methodology issues are rare. Since the introduction of electronic surveys, details on response times remain scarce. We aim to bridge a number of gaps by providing a real world example covering methodological choices and response times in detail. Methods: The objective of our e(lectronic)-Delphi study was to determine minimum standards for emergency departments (EDs) in the Netherlands. We opted for a two-part design with explicit decision rules. Part 1 focused on gathering and defining items; Part 2 addressed the main research question using an online survey tool. A two-person consensus rule was applied throughout: even after consensus on specific items was reached, panellists could reopen the discussion as long as at least two panellists argued similarly. Per round, the number of reminders sent and individual response times were noted. We also recorded the methodological considerations and evaluations made by the research team prior to as well as during the study. Results: The study was performed in eight rounds and an additional confirmation round. Response rates were 100% in all rounds, resulting in 100% consensus in Part 1 and 96% consensus in Part 2. Our decision rules proved to be stable and easily applicable. Items with negative advice required more rounds before consensus was reached. Response delays were mostly due to late starts, but once panellists started, they nearly always finished the questionnaire on the same day. Reminders often yielded rapid responses. Intra-individual differences in response time were large, but quick responders remained quick. Conclusions: We advise those considering Delphi study to follow the CREDES guideline, consider a two-part design, invest in personal commitment of the panellists, set clear decision rules, use a consistent lay-out and send out your reminders early. Adopting this overall approach may assist researchers in future Delphi studies and may help to improve the quality of Delphi designs in terms of improved rigor and higher response rates.
MeSH term(s)	Consensus ; Delphi Technique ; Humans ; Medicine ; Netherlands ; Physicians
Language	English
Publishing date	2020-06-15
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ISSN	1471-2288
ISSN (online)	1471-2288
DOI	10.1186/s12874-020-01029-4
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Article ; Online: Stijging lichte letsels bij de huisarts valt samen met daling op de SEH.

Panneman, Martien J M / Blatter, Birgitte M / Gaakeer, Menno I / Jansen, Tessa / van Beeck, Ed F

Nederlands tijdschrift voor geneeskunde

2020 Volume 164

Abstract: Objective: In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital ... ...

Title translation	Decrease in minor injury related visits to Emergency Departments coincides with higher numbers of primary care contacts.
Abstract	Objective: In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital admission. We investigated how the number of injury-related emergency department visits and GP contacts evolved over the period 2013-2017. Design: Retrospective observational trend study. Method: To calculate the trend in emergency department visits in the Netherlands, we used data from the injury information system (LIS) for the period 2013-2017. To calculate the trend in GP contacts (GP practices as well as GP centres), we used data from the NivelZorgregistraties (Nivel medical records). In order to compare the trends, we distinguished between minor and major injuries. The numbers from the records were extrapolated to numbers for the whole of the Netherlands. Results: In the period studied, the number of patients with minor injuries who visited the ED dropped by 38.5%, while the number of patients with major injuries (fractures and brain injuries) increased by 4.1%. In the same period, the number of GP contacts for minor injuries at GP practices increased by 25% and at GP centres by 43%; the number of primary care contacts for major injuries increased by 5.1% (GP practices) and 31% (GP centres) respectively. Conclusion: The role of general practitioners in the treatment of patients with minor injuries is increasing. The trend in major injuries is a better indicator for monitoring accidents and violence in the Netherlands. Conflict of interest and financial support: none declared.
MeSH term(s)	Emergency Service, Hospital/trends ; Female ; General Practitioners/trends ; Humans ; Male ; Netherlands ; Practice Patterns, Physicians'/trends ; Primary Health Care/trends ; Retrospective Studies ; Wounds and Injuries/therapy
Language	Dutch
Publishing date	2020-05-28
Publishing country	Netherlands
Document type	Journal Article ; Observational Study
ZDB-ID	82073-8
ISSN	1876-8784 ; 0028-2162
ISSN (online)	1876-8784
ISSN	0028-2162
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Article: THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY.

Candel, Bart G J / Raven, Wouter / Nissen, Søren Kabell / Morsink, Marlies E B / Gaakeer, Menno I / Brabrand, Mikkel / van Zwet, Erik W / de Jonge, Evert / de Groot, Bas

The Journal of emergency medicine

2023 Volume 65, Issue 1, Page(s) 7–16

Abstract: Background: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, ...

Abstract	Background: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. Objective: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). Methods: A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). Results: A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. Conclusion: No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
MeSH term(s)	Humans ; Adolescent ; Young Adult ; Adult ; Middle Aged ; Blood Pressure/physiology ; Heart Rate ; Cohort Studies ; Emergency Service, Hospital ; Hypotension
Language	English
Publishing date	2023-04-22
Publishing country	United States
Document type	Multicenter Study ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	605559-x
ISSN	0736-4679
ISSN	0736-4679
DOI	10.1016/j.jemermed.2023.04.009
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Article ; Online: Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department.

Candel, Bart Gerard Jan / Nissen, Søren Kabell / Nickel, Christian H / Raven, Wouter / Thijssen, Wendy / Gaakeer, Menno I / Lassen, Annmarie Touborg / Brabrand, Mikkel / Steyerberg, Ewout W / de Jonge, Evert / de Groot, Bas

Critical care medicine

2023 Volume 51, Issue 7, Page(s) 881–891

Abstract: Objectives: Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in ...

Abstract	Objectives: Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). Design: International multicenter cohort study. Setting: Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. Patients: All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). Measurements and main results: Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. Conclusions: The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
MeSH term(s)	Humans ; Aged ; Early Warning Score ; Hospital Mortality ; Cohort Studies ; Emergency Service, Hospital ; Vital Signs ; ROC Curve
Language	English
Publishing date	2023-03-23
Publishing country	United States
Document type	Multicenter Study ; Journal Article
ZDB-ID	197890-1
ISSN	1530-0293 ; 0090-3493
ISSN (online)	1530-0293
ISSN	0090-3493
DOI	10.1097/CCM.0000000000005842
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Article ; Online: Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study.

Candel, Bart Gj / Dap, Saimi / Raven, Wouter / Lameijer, Heleen / Gaakeer, Menno I / de Jonge, Evert / de Groot, Bas

European journal of internal medicine

2021 Volume 95, Page(s) 74–79

Abstract: Objective: The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED).: Methods: Observational multicenter cohort study using the ...

Abstract	Objective: The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). Methods: Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. Results: Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. Conclusions: Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.
MeSH term(s)	Cohort Studies ; Emergency Service, Hospital ; Female ; Hospital Mortality ; Humans ; Intensive Care Units ; Male ; Retrospective Studies ; Risk Assessment ; Sex Characteristics ; Triage
Language	English
Publishing date	2021-09-12
Publishing country	Netherlands
Document type	Journal Article ; Multicenter Study ; Observational Study
ZDB-ID	1038679-8
ISSN	1879-0828 ; 0953-6205
ISSN (online)	1879-0828
ISSN	0953-6205
DOI	10.1016/j.ejim.2021.09.001
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Article ; Online: Minimum operational standards for 24/7 available emergency departments in the Netherlands: a first step taken by emergency physicians using an e-Delphi approach.

Gaakeer, Menno I / Veugelers, Rebekka / Patka, Peter / Huijsman, Robbert

European journal of emergency medicine : official journal of the European Society for Emergency Medicine

2017 Volume 26, Issue 2, Page(s) 86–93

Abstract: Objective: The objective of this study was to effectuate a consensus of emergency physicians on minimum requirements for facility, diagnostic, and medical specialist availability as a first step toward minimum operational standards for 24/7 available ... ...

Abstract	Objective: The objective of this study was to effectuate a consensus of emergency physicians on minimum requirements for facility, diagnostic, and medical specialist availability as a first step toward minimum operational standards for 24/7 available emergency departments (EDs) in the Netherlands. Patients and methods: A two-part e-Delphi through online survey was performed between January 2015 and May 2016, using a panel of 20 experts in emergency medicine. The aim of part I was to reach an agreement on a list of possible ED elements and their definitions. The second part addressed the actual study objective to reach consensus on operational standards. Successive rounds were submitted to the members of the panel online using SurveyMonkey. Results of each survey round were discussed and interpreted in agreement with all authors in preparation for the next round. Reaching consensus, defined as 70% or more agreement or disagreement among the panel, on the level of all items was the endpoint of this study. Results: Both parts I and II required five rounds. The dropout rate of the expert panel remained zero. The availability of 52 facilities and diagnostic functionalities and the manner in which 17 medical specialties should be available to every 24/7 ED were agreed upon by the expert panel. Conclusion: An expert panel agreed upon minimum operational standards for EDs in the Netherlands. These results are helpful as a first step toward a more widely supported standard for future 24/7 available EDs in the Netherlands and in addition to this other urgent care facilities.
MeSH term(s)	Consensus ; Delphi Technique ; Emergency Medicine/standards ; Emergency Service, Hospital/standards ; Humans ; Netherlands ; Physicians/standards ; Practice Patterns, Physicians'/standards ; Quality Indicators, Health Care
Language	English
Publishing date	2017-08-17
Publishing country	England
Document type	Journal Article
ZDB-ID	1233544-7
ISSN	1473-5695 ; 0969-9546
ISSN (online)	1473-5695
ISSN	0969-9546
DOI	10.1097/MEJ.0000000000000494
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Article ; Online: Age-adjusted interpretation of biomarkers of renal function and homeostasis, inflammation, and circulation in Emergency Department patients.

Candel, Bart G J / Khoudja, Jamèl / Gaakeer, Menno I / Ter Avest, Ewoud / Sir, Özcan / Lameijer, Heleen / Hessels, Roger A P A / Reijnen, Resi / van Zwet, Erik / de Jonge, Evert / de Groot, Bas

Scientific reports

2022 Volume 12, Issue 1, Page(s) 1556

Abstract: Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to ( ... ...

Abstract	Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to (patho)-physiologic changes. The aim of this study was therefore to assess the effect of age on the case-mix adjusted association between biomarkers of renal function and homeostasis, inflammation and circulation and in-hospital mortality. This observational multi-center cohort study has used the Netherlands Emergency department Evaluation Database (NEED), including all consecutive ED patients ≥ 18 years of three hospitals. A generalized additive logistic regression model was used to visualize the association between in-hospital mortality, age and five blood tests (creatinine, sodium, leukocytes, C-reactive Protein, and hemoglobin). Multivariable logistic regression analyses were used to assess the association between the number of abnormal blood test values and mortality per age category (18-50; 51-65; 66-80; > 80 years). Of the 94,974 included patients, 2550 (2.7%) patients died in-hospital. Mortality increased gradually for C-reactive Protein (CRP), and had a U-shaped association for creatinine, sodium, leukocytes, and hemoglobin. Age significantly affected the associations of all studied blood tests except in leukocytes. In addition, with increasing age categories, case-mix adjusted mortality increased with the number of abnormal blood tests. In summary, the association between blood tests and (adjusted) mortality depends on age. Mortality increases gradually or in a U-shaped manner with increasing blood test values. Age-adjusted numerical scores may improve risk stratification. Our results have implications for interpretation of blood tests and their use in risk stratification tools and acute care guidelines.Trial registration number Netherlands Trial Register (NTR) NL8422, 03/2020.
MeSH term(s)	Emergency Service, Hospital
Language	English
Publishing date	2022-01-28
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2615211-3
ISSN	2045-2322 ; 2045-2322
ISSN (online)	2045-2322
ISSN	2045-2322
DOI	10.1038/s41598-022-05485-4
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Article ; Online: Terrorist Attacks against Hospitals: World-Wide Trends and Attack Types.

Ulmer, Nitzan / Barten, Dennis G / De Cauwer, Harald / Gaakeer, Menno I / Klokman, Vincent W / van der Lugt, Monique / Mortelmans, Luc J / van Osch, Frits H M / Tan, Edward C T H / Boin, Arjen

Prehospital and disaster medicine

2022 Volume 37, Issue 1, Page(s) 25–32

Abstract: Background: Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The ... ...

Abstract	Background: Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The extent, incidence, and characteristics of terrorist attacks against hospitals are unknown. Therefore, the objective of this study was to identify and to characterize terrorist attacks against hospitals reported to the Global Terrorism Database (GTD) over a 50-year period. Methods: The GTD was used to search for all terrorist attacks against hospitals from 1970-2019. Analyses were performed on temporal factors, location, attack and weapon type, and number of casualties or hostages. Chi-square tests were performed to evaluate trends over time and differences in attack types per world region. Results: In total, 454 terrorist attacks against hospitals were identified in 61 different countries. Of these, 78 attacks targeted a specific person within the hospital, about one-half (52.6%) involved medical personnel. There was an increasing trend in yearly number of attacks from 2008 onwards, with a peak in 2014 (n = 41) and 2015 (n = 41). With 179 incidents, the "Middle East & North Africa" was the most heavily hit region of the world, followed by "South Asia" with 125 attacks. Bombings and explosions were the most common attack type (n = 270), followed by 77 armed assaults. Overall, there were 2,746 people injured and 1,631 fatalities. In three incidents, hospitals were identified as secondary targets (deliberate follow-up attack on a hospital after a primary incident elsewhere). Conclusion: This analysis of the GTD identified 454 terrorist attacks against hospitals over a 50-year period. It demonstrates that the threat is real, especially in recent years and in world regions where terrorism is prevalent. The findings of this study may help to create or further improve contingency plans for a scenario wherein the hospital becomes a target of terrorism.
MeSH term(s)	Databases, Factual ; Disaster Planning ; Hospitals ; Humans ; Terrorism
Language	English
Publishing date	2022-01-18
Publishing country	United States
Document type	Journal Article
ZDB-ID	1025975-2
ISSN	1945-1938 ; 1049-023X
ISSN (online)	1945-1938
ISSN	1049-023X
DOI	10.1017/S1049023X22000012
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