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Emergency Medicine Journal current issue



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Highlights from this issue

2017-11-23T07:59:42-08:00

The corridors of uncertainty: a focus on emergency department admission processes

In this issue of the Emergency Medicine Journal we have two papers exploring admission processes; hospital admission thresholds and admission avoidance.

First, Wyatt and colleagues, in a retrospective analysis of a database of over 20 million (!) patients, examine hospital admission thresholds across 47 EDs over a 5 year period. After adjusting for various measures of acuity, they demonstrate a 3% reduction in admissions over the study period. The authors estimate that 137 000 hospital admissions were avoided across selected hospitals in 2015. This important work demonstrate how Emergency Medicine practice is changing, with ED clinicians adopting a higher threshold for admission, despite increasing acuity and medical complexity. The accompanying commentary by Boyle and Weber urges us to be mindful that policies that encourage avoidance of hospital admission at all costs may not always be in the best interests...




Are rising admission thresholds good medicine?

2017-11-23T07:59:42-08:00

Like many emergency physicians of a certain age, we find ourselves nostalgic for a time when it felt easier to admit patients into the hospital than now. Many of us now find ourselves feeling that we discharge many patients from the ED who we would have admitted years ago. It turns out that this hunch is correct. In an enormous retrospective database study, Steven Wyatt et al1 examined admission thresholds across 47 EDs in England over a 5-year period. They used a simple regression model to adjust for known predictors of admission, including robustly recorded items such as age and sex, and less well recorded items such as diagnosis.

Initially, the conversion rate (the number of admissions divided by the number of attendances) looks similar across the years, but when adjusted for various measures of acuity, there is a 3% reduction in admissions over the 5-year period....




Changes in admission thresholds in English emergency departments

2017-11-23T07:59:42-08:00

Background

The most common route to a hospital bed in an emergency is via an Emergency Department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED.

Methods

We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led EDs in England between April 2010 and March 2015. We used mixed-effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups: ambulance-conveyed children, walk-in children, ambulance-conveyed adults and walk-in adults.

Results

23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010–March 2011 (year 1) and April 2014–March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed negligiblybetween year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics, the odds of admission over the 5-year period had reduced by 15.2% (95% CI 13.4% to 17.0%) for ambulance-conveyed children, 22.6% (95% CI 21.7% to 23.5%) for walk-in children, 20.9% (95% CI 20.4% to 21.5%) for ambulance conveyed adults and 22.9% (95% CI 22.4% to 23.5%) for walk-in adults.

Conclusions

The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.




Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis

2017-11-23T07:59:42-08:00

Objective

Children with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children to be treated with intravenous antibiotics at home and aimed to describe the characteristics of patients treated on this pathway and in hospital and to evaluate the outcomes.

Methods

This is a prospective, observational cohort study of children aged 6 months–18 years attending the ED with uncomplicated moderate/severe cellulitis in March 2014–January 2015. Patients received either intravenous ceftriaxone at home or intravenous flucloxacillin in hospital based on physician discretion. Primary outcome was treatment failure defined as antibiotic change within 48 hours due to inadequate clinical improvement or serious adverse events. Secondary outcomes include duration of intravenous antibiotics and complications.

Results

115 children were included: 47 (41%) in the home group and 68 (59%) in the hospital group (59 hospital-only, 9 transferred home during treatment). The groups had similar clinical features. 2/47 (4%) of the children in the home group compared with 8/59 (14%) in the hospital group had treatment failure (P=0.10). Duration of intravenous antibiotics (median 1.9 vs 1.8 days, P=0.31) and complications (6% vs 10%, P=0.49) were no different between groups. Home treatment costs less, averaging $A1166 (£705) per episode compared with $A2594 (£1570) in hospital.

Conclusions

Children with uncomplicated cellulitis may be able to avoid hospital admission via a home intravenous pathway. This approach has the potential to provide cost and other benefits of home treatment.




Predicting outcomes in traumatic out-of-hospital cardiac arrest: the relevance of Utstein factors

2017-11-23T07:59:42-08:00

Background

Given low survival rates in cases of traumatic out-of-hospital cardiac arrest (OHCA), there is a need to identify factors associated with outcomes. We aimed to investigate Utstein factors associated with achieving return of spontaneous circulation (ROSC) and survival to hospital in traumatic OHCA.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify cases of traumatic OHCA that received attempted resuscitation and occurred between July 2008 and June 2014. We excluded cases aged <16 years or with a mechanism of hanging or drowning.

Results

Of the 660 traumatic OHCA patients who received attempted resuscitation, ROSC was achieved in 159 patients (24%) and 95 patients (14%) survived to hospital (ROSC on hospital handover). Factors that were positively associated with achieving ROSC in multivariable logistic regression models were age ≥65 years (adjusted OR (AOR)=1.56, 95% CI: 1.01 to 2.43) and arresting rhythm (shockable (AOR=3.65, 95% CI: 1.64 to 8.11) and pulseless electrical activity (AOR=2.15, 95% CI: 1.36 to 3.39) relative to asystole). Similarly, factors positively associated with survival to hospital were arresting rhythm (shockable (AOR=3.92, 95% CI: 1.64 to 9.41) relative to asystole), and the mechanism of injury (falls (AOR=2.16, 95% CI: 1.03 to 4.54) relative to motor vehicle collisions), while trauma type (penetrating (AOR=0.27, 95% CI: 0.08 to 0.91) relative to blunt trauma) and event region (rural (AOR=0.39, 95% CI: 0.19 to 0.80) relative to urban) were negatively associated with survival to hospital.

Conclusions

Few patient and arrest characteristics were associated with outcomes in traumatic OHCA. These findings suggest there is a need to incorporate additional information into cardiac arrest registries to assist prognostication and the development of novel interventions in these trauma patients.




Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan

2017-11-23T07:59:42-08:00

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed by emergency physicians has been gaining acceptance as a less invasive technique than resuscitative thoracotomy.

Objective

To evaluate access-related complications and duration of occlusions during REBOA.

Methods

Patients with haemorrhagic shock requiring REBOA, from 18 hospitals in Japan, included in the DIRECT-IABO Registry were studied. REBOA-related characteristics were compared between non-survivors and survivors at 24 hours. 24-Hour survivors were categorised into groups with small (≤8 Fr), large (≥9 Fr) or unusual sheaths (oversized or multiple) to assess the relationship between the sheath size and complications. Haemodynamic response, occlusion duration and outcomes were compared between groups with partial and complete REBOA.

Results

Between August 2011 and December 2015, 142 adults undergoing REBOA were analysed. REBOA procedures were predominantly (94%) performed by emergency medicine (EM) physicians. The median duration of the small sheath (n=53) was 19 hours compared with 7.5 hours for the larger sheaths (P=0.025). Smaller sheaths were more likely to be removed using external manual compression (96% vs 45%, P<0.001). One case of a common femoral artery thrombus (large group) and two cases of amputation (unusual group) were identified. Partial REBOA was carried out in more cases (n=78) and resulted in a better haemodynamic response than complete REBOA (improvement in haemodynamics, 92% vs 70%, P=0.004; achievement of stability, 78% vs 51%, P=0.007) and allowed longer occlusion duration (median 58 vs 33 min, P=0.041). No statistically significant difference in 24-hour or 30-day survival was found between partial and complete REBOA.

Conclusion

In Japan, EM physicians undertake the majority of REBOA procedures. Smaller sheaths appear to have fewer complications despite relatively prolonged placement and require external compression on removal. Although REBOA is a rarely performed procedure, partial REBOA, which may extend the occlusion duration without a reduction in survival, is used more commonly in Japan.




Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury

2017-11-23T07:59:42-08:00

Objectives

To determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) in a prospective longitudinal observational multicentre study. Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression.

Methods

This was a prospective observational study conducted between January 2013 and February 2014 in three trauma centres in the Netherlands. Patients aged 16 years and older with a GCS score of 9–15 on admission to the ED, with loss of consciousness and/or amnesia were prospectively enrolled. Follow-up questionnaires were completed at 2 weeks and 3 months after injury with the Head Injury Symptom Checklist, the Hospital Anxiety and Depression Scale and RTW scale.

Results

In total, 628 patients were enrolled in the study, 469 completed the 2-week questionnaire (75%) at 2 weeks and 409 (65%) at 3 months. At 2 weeks, 238 (51%) had developed aPTH and at 3 months 95 (23%) had developed cPTH. Female gender, younger age, headache immediately at the ED and CT scan abnormalities increased the risk for aPTH. Risk factors for cPTH were female gender and headache at the ED. Patients with cPTH were less likely to have returned to work than those without cPTH (35% vs 14%, P=0.001). Patients with aPTH and cPTH more often report anxiety (20% and 28%, P=0.001) and depression (19% and 28%, P=0.001) after trauma in comparison with the group without PTH (10% anxiety and 8% depression).

Conclusions

PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH.




Emergency versus standard response: time efficacy of Londons Air Ambulance rapid response vehicle

2017-11-23T07:59:42-08:00

Objective

The potential increased risk of an emergency response using a rapid response vehicle (RRV) should only be accepted when it allows a clinically significant time saving for management of patients who are critically injured or sick. Air ambulance services often use an RRV to maintain operational resilience. We compared the RRV response time on emergency versus standard driving to inform emergency services of time efficacy of emergency response in an urban environment.

Methods

Prospective observational controlled study of response data of emergency and standard driving. An identical RRV shadowed the medical team until the team was dispatched to a job (emergency driving). The shadow RRV then drove to the same given location from the same origin location in equal traffic conditions being compliant with all traffic signals, road signs and speed limits (standard driving).

Results

The emergency response resulted in an estimated reduction in median response time of 14 min (95% CI 9 to 19) which represented a time saving of 54.9%. The estimated difference in distance travelled (0.6 km) was not statistically significant. Median speed was significantly higher when using an emergency response (46.1 IQR 39–53.4 km/hour) versus standard response (20.1 IQR 16.3–24.7 km/hour), with an estimated difference of –24.5 km/hour (95% CI –28.8 to –20.5).

Conclusions

The current study found RRVs to be significantly quicker when responding with lights, sirens and traffic rule exemptions compared with a response being compliant with all traffic signals, road signs and speed limits.




The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage

2017-11-23T07:59:42-08:00

Introduction

Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment.

Methods

Retrospective database review of the Trauma Audit and Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014. Patients were defined as Priority One if they received one or more LSIs from a previously defined list. Only patients with complete physiological data were included. Patients were categorised by the MPTT and existing triage tools using first recorded hospital physiology. Performance characteristics were evaluated using sensitivity, specificity and area under receiver operating characteristic (AUROC).

Results

During the study period, 218 985 adult patients were included in the TARN database. 127 233 (58.1%) had complete data: 55.6% male, aged 61.4 (IQR 43.1–80.0) years, Injury Severity Score 9 (IQR 9–16), 96.5% suffered blunt trauma and 24 791 (19.5%) were Priority One. The MPTT (sensitivity 57.6%, specificity 71.5%) outperformed all existing triage methods with a 44.7% absolute reduction in undertriage compared with existing UK civilian methods. AUROC comparison supported the use of the MPTT over other tools (P<0.001.)

Conclusion

Within a civilian trauma registry population, the MPTT demonstrates improved performance at predicting need for LSI, with the lowest rates of undertriage and an appropriate level of overtriage. We suggest the MPTT be considered as an alternative to existing triage tools.




Perceived support at work after critical incidents and its relation to psychological distress: a survey among prehospital providers

2017-11-23T07:59:42-08:00

Introduction

Prehospital providers are at increased risk for psychological distress. Support at work after critical incidents is believed to be important for providers, but current guidelines are in need of more scientific evidence. This study aimed to investigate: (1) to what extent prehospital providers experience support at work; (2) whether support at work is directly associated with lower distress and (3) whether availability of a formal peer support system is related to lower distress via perceived colleague support.

Methods

This cross-sectional study surveyed prehospital providers from eight western industrialised countries between June and November 2014. A supportive work environment was operationalised as perceived management and colleague support (Job Content Questionnaire), availability of a formal peer support system and having enough time to recover after critical incidents. The outcome variable was psychological distress (Kessler 10). We conducted multiple linear regression analyses and mediation analysis.

Results

Of the 813 respondents, more than half (56.2%) were at moderate to high risk of psychological distress. Participants did not consistently report support at work (eg, 39.4% were not aware of formal peer support). Perceived management support (b (unstandardised regression coefficient)=–0.01, 95% CI –0.01 to 0.00), having enough time to recover after critical incidents (b=–0.07, 95% CI –0.09 to –0.04) and perceived colleague support (b=–0.01, 95% CI –0.01 to 0.00) were related to lower distress. Availability of formal peer support was indirectly related to lower distress via increased perceived colleague support (β=–0.04, 95% CI –0.02 to –0.01).

Conclusions

Prehospital providers at risk of psychological distress may benefit from support from colleagues and management and from having time to recover after critical incidents. Formal peer support may assist providers by increasing their sense of support from colleagues. These findings need to be verified in a longitudinal design.




Spotting the black swan: why emergency medicine is ahead of the curve

2017-11-23T07:59:42-08:00

"Black Swans", originally described as an economic theory, are unexpected events whose potential to occur only becomes apparent after they have happened. The concept is very relevant to the practice of Emergency Medicine and this article explores how black swans impact on emergency care and how staff unconsciously aim to mitigate against them.




Identifying discordance between senior physicians and trainees on the root cause of ED revisits

2017-11-23T07:59:42-08:00

Objective

Analysis of 72-hour ED revisits is a common emergency medicine quality assurance (QA) practice. Our aim was to compare the perceived root cause for 72-hour ED revisits between senior physicians (attendings) and trainees. We proposed that discordance in perception of why the revisit occurred would guide improvements in 72-hour revisits QA and elucidate innovative educational opportunities.

Methods

Questionnaire-based observational study conducted in an urban academic paediatric ED. Treating attendings and trainees independently completed questionnaires on revisit cases. The primary outcome was the revisit’s perceived root cause, dichotomised into ‘potential medical deficiency’ or ‘not potential medical deficiency’. Discordance between provider pairs was measured, stratified by revisit disposition.

Results

During the study period, 31 630 patients were treated in the ED, 559 returned within 72 hours and 218 met inclusion criteria for paired analysis. The proportion of cases assigned ‘potential medical deficiency’ by the attending and trainee was 13% and 9%, respectively. Discordance in the dichotomised root cause between attendings and trainees was 17% (38/218, 95% CI 12% to 22%). Revisit cases requiring admission revealed attending-trainee discordance of 25% (23/92, 95% CI 16% to 34%).

Conclusions

Attendings and trainees frequently disagree on whether a potential medical deficiency was the root cause for an ED revisit, with more disagreement noted for cases requiring admission. These findings support the premise that there may be opportunities to improve 72-hour revisits QA systems through trainee integration. Finally, reuniting attending-trainee pairs around revisit cases may be a novel educational opportunity.




De Winters wave

2017-11-23T07:59:42-08:00

Clinical introduction

A 45-year-old man was admitted to the ED because of an acute retrosternal chest pain which prolonged for 20 min. He was overweight and a regular smoker. When admitted the pain had disappeared and the physical examination remained normal. The ECG was normal (figure 1). The ultrasensitive T troponin remained negative (H0 and H+3). He was treated for a non-ST elevation myocardial infarction and transferred to the inpatient ward.

A few hours later, he once again presented with severe and continuous chest pain. The ECG was performed 5 min after the onset of the pain (figure 2)

Question

What is your diagnosis?

  • Normal ECG

  • Hyperkalaemia

  • Acute occlusion of the left anterior descending coronary artery

  • Hypocalcaemia

  • Answer: C

    The second ECG (with pain) shows wide, positive and symmetrical T waves, with a depressed J point from V1 to V3 (*)....




    Emergency procedures for patients with a continuous flow left ventricular assist device

    2017-11-23T07:59:42-08:00

    The number of ventricular assist devices (VADs) being implanted for terminal heart failure is rising at an exponential rate. These implanted patients have a decreased mortality, but still have significant morbidities, as the prevalence of these patients increases in the community. When VAD patients are discharged to home, they will very likely require emergency medical services (EMSs) and emergency medical doctors (EDs) with their future care. The interface of these patients with the community would suggest an increasing prevalence of encounters requiring the need for acute medical care. This will place the initial responsibility of these patients in the hands of EMS first responders and emergency room providers. To date, there is very little literature published on out-of-hospital or ED care for VAD patients. Most EMS personnel and ED feel uncomfortable treating a patient with a VAD because they have not had sufficient exposure. The cardiovascular treatment of VAD patients in the field can pose different challenges typically encountered including difficulties measuring a pulse and sometimes undetectable BP. Despite these unique challenges, official guidelines or even standard operating procedures regarding the emergency treatment of VAD patients are still lacking. We present a basic overview of the most commonly used left VAD systems and propose guidelines that should be followed in the event of an emergency with a VAD patient out of hospital.




    Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices

    2017-11-23T07:59:42-08:00

    Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.




    He was brought in blue... with an LVAD

    2017-11-23T07:59:42-08:00

    It was a long time ago.

    He was blue. He was breathless and he was plugged in to an LVAD. The crew knew he needed to get to the LVAD Centre, but they didn’t think he would make it. They brought him to me instead. With some oxygen he felt better. His name was Leonardi and he gave a good history for pneumonia ... fever, cough, yellow sputum.

    He had signs at the left base and a belt with a bulky controller for his LVAD. There was no flashing light, no sound. It came as no surprise that he had no veins. While the Cardiologist phoned the LVAD Centre I put in a femoral line, checked a blood gas and started antibiotics. His central venous saturation was 15% ... 15%? Turning back to Leonard it was obvious he was fading. From the LVAD Centre we learned that...




    BET 1: Can the Manchester Acute Coronary Syndromes and Troponin-only Manchester Acute Coronary Syndromes decision aids rule out acute coronary syndromes in the emergency department?

    2017-11-23T07:59:42-08:00

    A short-cut review was carried out to establish whether the Manchester Acute Coronary Syndromes (MACS) and Troponin-only MACS (T-MACS) decision aids can safely rule out acute coronary syndromes in patients presenting to the ED with suspected cardiac chest pain. Six studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that both rules have high sensitivity for acute coronary syndromes, including the detection of major adverse cardiac events at 30 days. The original MACS algorithm may have marginally greater sensitivity than T-MACS but has inferior specificity and requires the use of a biomarker assay (for heart-type fatty acid binding protein) that is not currently widely used in practice.




    Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary

    2017-11-23T07:59:42-08:00

    Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.

    The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently...




    BET 2: Sharing decisions for patients with suspected cardiac chest pain in the emergency department

    2017-11-23T07:59:42-08:00

    A short-cut review was carried out to establish whether shared decision making used alongside a decision aid can lead to greater patient satisfaction, lower healthcare resource use and non-inferior clinical outcomes in patients with suspected acute coronary syndromes. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that the use of shared decision-making tools in the ED for management of patients with low-risk chest pain appears to be beneficial to the patient and the physician. Use of these shared decision-making tools appears to increase patient knowledge and satisfaction, while decreasing decision conflict and resource use, without causing additional negative outcomes for the patient.




    Abstracts from international Emergency Medicine Journals

    2017-11-23T07:59:42-08:00

    Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.




    1 Patient acceptability and feasibility of HIV testing in emergency departments in the UK - a systematic review and meta-analysis

    2017-11-23T07:59:42-08:00

    Background

    NICE 2016 HIV testing guidelines now include the recommendation to offer HIV testing in Emergency Departments, in areas of high prevalence,1 to everyone who is undergoing blood tests. 23% of England’s local authorities are areas of high HIV prevalence (>2/1000) and are therefore eligible.2 So far very few Emergency Departments have implemented routine HIV testing. This systematic review assesses evidence for two implementation considerations: patient acceptability (how likely a patient will accept an HIV test when offered in an Emergency Department), and feasibility, which incorporates staff training and willingness, and department capacity, (how likely Emergency Department staff will offer an HIV test to an eligible patient), both measured by surrogate quantitative markers.

    Methods and results

    Three medical databases were systematically searched for reports of non-targeted HIV testing in UK Emergency Departments. A total of 1584 unique papers were found, 9 full text articles were critically appraised, and 7 studies included in meta-analysis. There is a combined patient sample of 1 01 975. The primary outcome, patient acceptability of HIV testing in Emergency Departments (number of patients accepting an HIV test, as a proportion of those offered) is 54.1% (CI 40.1, 68.2). Feasibility (number of tests offered, as a proportion of eligible patients) is 36.2% (CI 9.8, 62.4).

    Conclusions

    For an Emergency Department considering introducing routine HIV testing, this review suggests an opt-out publicity-lead strategy. Utilising oral fluid and blood tests would lead to the greatest proportion of eligible patients accepting an HIV test. For individual staff who are consenting patients for HIV testing, it may be encouraging to know that there is >50% chance the patient will accept an offer of testing.

    Table 1

    Summary table of data extracted from final 7 studies, with calculated acceptability and feasibility if appropriate, and GRADE score. Studies listed in chronological order of data collection. GRADE working group evidence grades: 4= high quality, 3= moderate quality, 2= low quality, 1 or below = very low quality. (*study conclusion reports this figure is inaccurate)

    Figure 1

    Patients accepting HIV tests, and being offered HIV tests, as a proportion of the eligible sample

    References

  • National Institute for Health and Care Excellence, Public Health England. HIV testing: Increasing uptake among people who may have undiagnosed HIV. 2016 1 December 2016.

  • Public Health England. HIV prevalence by Local Authority of residence to end December 2015. Table No.1: 2016. Public Health Engand; 2016.




  • 2 Major incident triage and the implementation of a new triage tool, the MPTT-24

    2017-11-23T07:59:42-08:00

    Introduction

    Over the last decade, a number of European cities including London, have witnessed high profile terrorist attacks resulting in major incidents with large numbers of casualties. Triage, the process of categorising casualties on the basis of their clinical acuity, is a key principle in the effective management of major incidents.

    The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool which in comparison to existing triage tools, including the 2013 UK NARU Sieve, demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations.

    To improve the applicability and usability of the MPTT we increased the upper respiratory rate threshold to 24 breaths per minute (MPTT-24), to make it divisible by four, and included an assessment of external catastrophic haemorrhage. The aim of this study was to conduct a feasibility analysis of the proposed MPTT-24 (figure 1).

    Figure 1

    MPTT-24

    Methods

    A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they had received one or more life-saving interventions.

    Using first recorded hospital physiology, patients were categorised as P1 or not-P1 by existing triage tools and both MPTT and MPTT-24. Performance characteristics were evaluated using sensitivity, specificity, under and over-triage with a McNemar test to determine statistical significance.

    Results

    Basic study characteristics are shown in Table 1. Both the MPTT and MPTT-24 outperformed all existing triage methods with a statistically significant (p<0.001) absolute reduction of between 25.5%–29.5% in under-triage when compared to existing UK civilian methods (NARU Sieve). In both populations the MPTT-24 demonstrated an absolute reduction in sensitivity with an increase in specificity when compared to the MPTT. A statistically significant difference was observed between the MPTT and MPTT-24 in the way they categorised TARN and JTTR cases as P1 (p<0.001).

    Table 1

    Study characteristics

    Table 2

    Performance analysis

    Conclusion

    Existing UK methods of primary major incident triage, including the NARU Sieve, are not fit for purpose, with unacceptably high rates of under-triage. When compared to the MPTT, the MPTT-24 allows for a more rapid triage assessment and continues to outperform existing triage tools at predicting need for life-saving intervention. Its use should be considered in civilian and military major incidents.




    3 Derivation and internal validation of a clinical decision rule to guide whole body computed tomography scanning in trauma

    2017-11-23T07:59:42-08:00

    Background

    There are no widely accepted validated clinical decision rules for the use of WBCT in trauma. Given the potential risks and costs, there is a clear need for a clinical decision rule (CDR) to safely guide targeted use of WBCT. We aimed to derive a CDR to guide clinical decisions on WBCT utilisation by detecting patients at high and low risk of multi-region trauma.

    Methods

    We retrospectively identified consecutive patients who had presented to a major trauma centre with suspected major trauma. Study took place at Aintree University Hospital, Merseyside. After extracting data, we derived a clinical decision rule for detection of multi-region trauma by logistic regression and recursive partitioning. The primary outcome was defined as injuries of AIS≥2 in two or more body regions, while the secondary outcome was the presence of two injuries of AIS≥3 in two or more body regions. This rule was cross-validated on the original sample using bootstrapping.

    Results

    1608 patients were included in the study. The derived model combined a bespoke physiological score with mechanistic and anatomical factors. The physiological score identified the risk of multi-region injury at various cut-offs of age, systolic blood pressure, GCS, heart rate and respiratory rate. Patients were further categorised according to mechanism of injury and clinical findings, and specific physiological scores were applied to each category to determine which patients in these categories required WBCT. ‘High risk’ injury mechanisms included high falls and unprotected road traffic collisions. Clinical signs of injury were categorised by body region, including the head, chest, abdomen and pelvis (figure 1). The overall sensitivity of the clinical decision rule for the primary objective was 96.0% (95% CI:94.8 to 97.2) while the specificity was36.1% (95% CI:33.3 to 39.0). The negative likelihood ratio was 0.11. For the secondary objective the sensitivity was 98.5%, the negative likelihood ratio 0.04.

    Figure 1

    Conclusion

    This study derived a two stage CDR which was highly sensitive for identifying patients at high risk of multiregion injury. A prospective external validation study is now required to further refine and improve this model. This could provide a useful screening tool in the future.




    4 The risk of deterioration in CT identified mild traumatic brain injury: a systematic review and meta-analysis

    2017-11-23T07:59:42-08:00

    Background

    The optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13–15 patients with traumatic brain (TBI) injury identified by CT imaging. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED).

    Objective

    To estimate the risk of death, neurosurgery and clinical deterioration minor head injured patients with TBI identified by CT imaging, and assess which factors affect the risk of these outcomes.

    Figure 1

    Risk of neurosurgery stratified by the initial GCS of the study population

    Methods

    A systematic review and meta-analysis adhering to PRISMA standards of reporting. Four electronic data bases and a range of additional literature were searched using a highly sensitive search strategy. Study selection was performed by 2 independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks of: clinical deterioration, neurosurgery and death. Meta-regression was used to explore between study variation in outcome estimates using study characteristics. Factors assessed by individual studies as affecting the outcomes of interest were recorded and pooled within study risk factor effects were estimated where possible.

    Results

    4431 studies were identified by the search strategy, of which 123 studies were fully retrieved and 49 primary studies and 5 reviews met the inclusion criteria. The estimated pooled risk of the outcomes of interest were: clinical deterioration 11.7% (95% CI:11.7 to 15.8; neurosurgery 3.5% (95% CI:2.2% to 4.9%); death 1.4% (95% CI:0.8% to 2.2%). A large degree of between study variation in the estimates of the outcomes was identified. Multivariable meta-regression of study characteristics identified that mean age of the study population and mean initial GCS accounted for up to half of the variation in reported study outcomes. Within studies the following factors were found to affect the risk for these adverse outcomes: age; severity of injury; type of injury; initial GCS; anti-coagulation; anti-platelet medication; and injury severity scoring. When univariable within study risk factor effect estimates were pooled patients with isolated subarachnoid haemorrhage had an odds ratio of 0.19 for deterioration compared to other injury types.

    Figure 2

    Meta-regression of study factors predictive of neurosurgery

    Conclusion

    Minor head injured patients with brain injury identified by CT imaging have a clinically important risk of serious adverse outcomes. Research has identified the possible factors that affect this risk. However, these factors need to be incorporated into a validated multivariable prognostic model before low-risk patients can be reliably identified clinically and triaged to lower levels of care.

    Figure 3

    PRISMA flow-diagram showing selection of studies for inclusion in the systematic review




    5 A study analysing the diagnostic performance of ECG interpretation for 30-day major cardiac events in the emergency department

    2017-11-23T07:59:42-08:00

    Study objective

    This study evaluates the diagnostic accuracy of an Emergency Medicine (EM) clinician at identifying ischaemia on an ECG using 30-day major adverse cardiac events (MACE) as the primary outcome.

    Methods

    This is a secondary analysis of a prospective, multi-centre, observational cohort at 14 centres: the Bedside Evaluation of Sensitive Troponin study. All fourteen Emergency Departments were based in the United Kingdom. Emergency physicians’ assessments of the ECG were collected using a standardised form. Clinicians were asked to judge whether the ECG demonstrated ischaemia, the presence of ST depression (STD) and if there was abnormal T wave inversion (ATWI). Patients provided written informed consent and underwent serial high sensitivity troponin testing. 30 day follow-up was performed by research nurses using a standardised form via telephone. The primary outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, any cause of death and coronary revascularisation.

    Results

    In total, 756 patients were included in the analysis. Clinicians’ ECG diagnosis of ischaemia for 30-day MACE: ECG ischaemia produces a sensitivity (Sn) of 19.54% (95% CI:11.81% to 29.43%), specificity (Sp) of 93.27% (95% CI:91.10% to 95.05%), positive predictive value (PPV) of 27.42% (95% CI:18.47% to 38.65%) and negative predictive value (NPV) of 89.91% (95%CI 88.92% to 90.83%). ECG ST depression produces Sn of 16.09% (9.09% to 25.52%), Sp of 89.69% (87.13% to 91.89%), PPV 16.87 (10.68% to 25.62%), and NPV 89.15% (88.19% to 90.04%). ECG ATWI produces Sn of 4.60% (1.27% to 11.36%), Sp of 91.63% (89.27% to 93.62%), PPV of 6.67% (2.59% to 16.12%) and NPV of 88.07% (87.52% to 88.6).

    Conclusion

    This is the first prospective, multi-centre cohort study, that assess the diagnostic performance of EM clinician’s ECG interpretation, with 30-day MACE as the primary outcome. The findings are highly relevant to EM as they represent the ECG terms used by popular acute coronary syndrome clinical decision rules. In this study a clinician’s overall judgement of ischaemia has a better diagnostic performance compared to simple STD and ATWI. This may be due to an appreciation of morphology and the amount of deviation; future work should explore the effect of measuring deviation and analysing morphology.




    6 Prognostic value of the glasgow admission prediction score: hospital length of stay, mortality and hospital readmission

    2017-11-23T07:59:42-08:00

    Introduction

    As patient numbers presenting to emergency departments (ED) increase, with their myriad of comorbidities, early hospital admission prediction and demand modelling are crucial both in the ED and beyond. The Glasgow admission prediction score (GAPS) (figure 1)1 has already been shown to be accurate in predicting hospital admission from the ED at the point of triage.2 As demand on EDs increase, data driven models such as GAPS will become increasingly important for predicting patient course. However, GAPS has not previously been tested beyond the point of admission.

    Figure 1

    Aim

    To assess whether GAPS has the ability to predict hospital length of stay (LOS), six-month mortality and six-month hospital readmission.

    Methods

    Sampling was conducted in 2016 at the Sheffield Teaching Hospitals NHS foundation trust ED and the NHS Greater Glasgow and Clyde ED. Data were collected prospectively at the point of triage for all consecutive patients who presented to the ED during sampling times. GAPS was calculated independent of patient clinical management and recorded. Patients were followed up at six months, looking at length of any hospital admission, mortality and hospital readmission. Length of hospital stay, mortality and hospital readmission against GAPS was modelled using survival analysis.

    Results

    In total 1420 patients were recruited, 39.6% of these patients were initially admitted to hospital. At six months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged at any one time fell by 4.3% (95% confidence interval (CI) 3.2%–5.3%) per GAPS point increase. Figure 2 displays the Kaplan Meier curves for 6 month mortality. Cox regression showed a significant association between GAPS and mortality, with a hazard increase of 9% (95% CI:6.9% to 11.2%) for every point increase on GAPS. Figure 3 displays the Kaplan Meier curves for 6 month hospital readmission.

    Figure 2

    Discussion

    GAPS is a simple tool which utilises data routinely collected at triage. It is predictive of hospital admission, hospital length of stay, six-month all-cause mortality and six-month hospital readmission. Therefore, GAPS could be employed to aid staff in hospital bed planning, clinical decision making and ED resource allocation and utilisation.

    Figure 3

    References

  • Logan E, et al. Predicating admission at triage. Presented at International Acute Medicine Conference, Edinburgh 2016.

  • Cameron A, et al. A simple tool to predict admission at the time of triage. Emergency Medicine Journal2014.




  • 7 Mass casualty incidents: a review of triage severity planning assumptions

    2017-11-23T07:59:42-08:00

    Background

    Recent events involving a significant number of casualties have emphasised the importance of appropriate preparation for receiving hospitals, especially Emergency Departments, during the initial response phase of a major incident. Development of a mass casualty resilience and response framework in the Northern Trauma Network included a review of existing planning assumptions in order to ensure effective resource allocation, both in local receiving hospitals and system-wide.

    Existing planning assumptions regarding categorisation by triage level are generally stated as a ratio for P1:P2:P3 of 25%:25%:50% of the total number of injured survivors. This may significantly over-, or underestimate, the number in each level of severity in the case of a large-scale incident.

    Methods

    A pilot literature review was conducted of the available evidence from historical incidents in order to gather data regarding the confirmed number of overall casualties, ‘critical’ cases, admitted cases, and non-urgent or discharged cases. This data was collated and grouped by mechanism in order to calculate an appropriate severity ratio for each incident type.

    Results

    12 articles regarding mass casualty incidents from the last two decades were identified covering three main incident types: (1) Mass transportation crash, (2) Building fire, and (3) Bomb and related terrorist attacks and involving a total of 3615 injured casualties. The overall mortality rate was calculated as 12.3%. Table 1 summarises the available patient casualty data from each of the specific incidents reported and calculated proportions of critical (‘P1’), admitted (‘P2’), and non-urgent or ambulatory cases (‘P3’).

    Conclusions

    Despite the heterogeneity of data and range of incident type there is sufficient evidence to suggest that current planning assumptions are incorrect and a more refined model is required. An important finding is the variation in proportion of critical cases depending upon the mechanism. For example, a greater than expected proportion results from incidents involving a building fire whereas the existing model may over-estimate critical caseload in more ‘conventional’ incidents such as a transportation accident or even in terrorism-related incidents.

    A new model suggesting the proportions of casualties expected by severity categorisation and incident type is shown in table 2. A more detailed investigation is planned to further refine and develop this model.

    Table 1

    Table 2




    8 Different approaches needed to manage ED demand among different age-groups

    2017-11-23T07:59:42-08:00

    Background/objectives

    A variety of interventions have been proposed to manage rising demand for Emergency and Urgent Care, described by an NHS England review as unsustainable in the long term. However it is unlikely that any suggested approach will be equally suitable for the diverse population of ED users.

    We aimed to understand the patterns of demand amongst different types of patients attending ED. We also sought to understand the intended and unintended effects of demand management initiatives. Our study combined insights from routine data, a survey of ED patients, and qualitative interviews with ED staff. This paper describes the results of our analysis of the interviews.

    Methods

    We conducted semi-structured interviews with 25 ED and Urgent Care Centre staff across 7 hospital sites in Yorkshire and Humber between 25 April and 11 July 2016. The interview topic guide asked about 4 broad areas; job role, description of patients and their impact on demand, description of inappropriate attendance, and current/future initiatives to deal with rising demand. Interviews were transcribed verbatim and analysed using framework analysis. We analysed the results to identify groups of patients with different patterns of use of ED services. We also explored ED staff experiences of demand management initiatives, and their suggestions for future initiatives.

    Results

    Although we did not ask specifically about patients’ age, our analysis revealed that ED staff categorised attenders as children and young people, working age people, and older people. These groups had different reasons for attendance, different routes to the ED, different rate of non-urgent attendance, and different issues driving demand. Staff also described variation in the time taken to treat patients of different ages, with the oldest and youngest patients described as requiring the most time.

    There was no consensus amongst staff about the effectiveness of initiatives for managing demand. A strikingly wide variety of initiatives were mentioned including patient education, co-location of other services with ED (‘ED hubs’), and extending community-based services.

    Conclusion

    ED staff attribute distinctly different patterns of ED attendance to patients of different age groups, including reasons for attending ED, the route to the ED, and the rate of non-urgent attendance. Given this variation, proposed demand management interventions are likely to impact differently on different age groups, and one solution is unlikely to be optimal for all ages. Therefore a number of different approaches will be needed to manage ED demand among different age groups.




    9 Closed chest compressions reduce survival in a model of haemorrhage-induced traumatic cardiac arrest

    2017-11-23T07:59:42-08:00

    Background

    Closed chest compressions (CCC) are a key component of resuscitation from medical causes of cardiac arrest, but when haemorrhage, the leading cause of preventable battlefield deaths, is the likely cause there is little evidence to support their use. Resuscitation protocols for traumatic cardiac arrest (TCA) highlight the importance of addressing reversible causes, such as the administration of fluids to treat hypovolaemia. This study evaluated whether CCC were beneficial following haemorrhage-induced TCA and additionally whether resuscitation with blood improved physiological outcomes.

    Methods

    The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 using 39 terminally anesthetised Large White pigs (35 kg, 29–40 kg) instrumented for invasive physiological monitoring. Following instrumentation and baseline measurements, animals underwent tissue injury (captive bolt to the right thigh) and controlled haemorrhage (30% blood volume). Mean arterial blood pressure (MAP) was maintained at 45 mmHg for 60 min, followed by a further controlled haemorrhage to a MAP of 20 mmHg. As arterial blood and pulse pressures spontaneously deteriorated further over a 5 min period, the randomised resuscitation protocol was initiated as follows: CCC (n=6); IV 0.9% saline (Sal n=8); IV autologous whole blood (WB n=8); IV saline +chest compressions (Sal +CCC n=9); and IV whole blood +chest compressions (WB +CCC n=8). 3x10 ml/kg fluid boluses were administered using the Belmont Rapid Infuser (200 ml/min). CCC were performed using the LUCAS II Chest Compression System.

    Outcome was attainment of return of spontaneous circulation (ROSC) 15 min post-resuscitation. ROSC was categorised by MAP (MAP ≥50 mmHg=ROSC; MAP >20 <50 mmHg=partial ROSC; MAP ≤20 mmHg=dead).

    Figure 1

    Results

    Outcome was significantly worse in the group that received CCC compared to WB and Sal groups (6/6 dead versus 0/8 and 0/8 respectively) (p<0.0001).

    A significantly higher number of animals attained ROSC in WB compared to Sal group (6/8 versus 0/8 ROSC and 2/8 versus 8/8 partial ROSC respectively) (p=0.0069).

    There were some none significant differences between WB and WB+CCC groups (6/8 versus 5/8 ROSC, 2/8 versus 1/8 partial ROSC and 0/8 versus 2/8 dead respectively) (p=0.4411).

    No animals attained ROSC in the Sal and Sal+CCC groups however significantly more animals died in the Sal+CCC group (0/8 versus 0/9 ROSC, 8/8 versus 2/9 partial ROSC and 0/8 versus 7/9 dead respectively) (p=0.0023).

    Conclusions

    CCC were associated with increased mortality compared to intravenous fluid resuscitation. Resuscitation with whole blood demonstrated the greatest physiological benefit as demonstrated by highest numbers of animals achieving ROSC.




    10 Decision analysis modelling of diagnostic strategies for suspected pulmonary embolism in pregnancy: the DiPEP economic evaluation

    2017-11-23T07:59:42-08:00

    Background

    Using diagnostic imaging for suspected pulmonary embolism (PE) in pregnancy involves weighing the benefits, harms and costs of different approaches to selecting women for imaging.

    Objectives

    To estimate the effectiveness of diagnostic strategies for PE in pregnancy and postpartum, in terms of adverse outcomes from venous thromboembolism, bleeding and radiation exposure, and cost effectiveness, measured as the incremental cost per quality-adjusted life year (QALY).

    Methods

    Decision-analysis modelling was used to estimate costs incurred and expected outcomes from thromboembolism, bleeding and radiation exposure if a hypothetical cohort of pregnant or postpartum women based on the Diagnosis of PE in Pregnancy (DiPEP) study population were investigated for suspected PE using different strategies, including no imaging, selective imaging based on a clinical decision rule and imaging for all. Outcomes were modelled to estimate the quality-adjusted life years (QALYs) accrued by each strategy and the incremental cost per QALY gained by each strategy compared to the next most effective alternative. Threshold analysis explored the parameters required for a hypothetical clinical decision rule to be cost-effective.

    Results

    Decision analysis showed that a nonselective strategy of scanning all women with suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy. This finding was robust in sensitivity analysis and scenario analysis exploring assumptions in the model. Threshold analysis showed that a clinical decision rule to select women for imaging would need to have sensitivity exceeding 97.5% to be cost-effective compared to nonselective use of scanning.

    Figure 1

    Conclusion

    There is little potential for selective imaging based on a clinical decision rule to be cost-effective compared to a strategy of nonselective imaging for all women with suspected PE in pregnancy and postpartum.




    11 Topical nsaids for analgesia in traumatic corneal abrasions: a systematic review and meta-analysis

    2017-11-23T07:59:42-08:00

    Background

    Traumatic corneal abrasions are common ocular presenTations in the ED. There is no consensus regarding the most appropriate analgesia for this condition. Topical non-steroidal anti-inflammatory drugs (NSAIDs) have been suggested as pain-relief to minimise systemic adverse events associated with oral analgesia.

    Aim

    To identify and evaluate all randomised controlled trials (RCTs) comparing the use of topical NSAIDs with placebo or any alternative analgesic interventions in adults with traumatic corneal abrasions (including corneal abrasions arising from foreign body removal), to reduce pain, and its effects on healing time.

    Methods

    We searched MEDLINE, EMBASE, Cochrane Library and clinical trials registers up to 30/03/17. We did not use any date or language restrictions in the electronic searches for trials. We checked the reference lists of identified trials to search for further potentially relevant studies. Two review authors independently performed data extraction and assessed risks of bias in the included studies. We assessed risk of bias using the Cochrane risk of bias tool and rated the certainty of the evidence using GRADE.

    Results

    We included nine studies that met the inclusion criteria, reporting data on 637 participants. These studies compared five types of topical NSAIDs (0.1% indomethacin, 0.03% flurbiprofen, 0.5% ketorolac, 1% indomethacin, 0.1% diclofenac) to control (consisting of standard care and in four studies used placebo eye drops). Overall, the studies were at an unclear or high risk of bias (particularly selection and reporting bias). None of the included studies reported the primary outcome measures of this review, namely participant-reported pain intensity reduction of 30% or more or 50% or more at 24 hours. Four trials, that included data on 481 participants receiving NSAIDs or control (placebo/standard care), reported on the use of ‘rescue’ analgesia at 24 hours as a proxy measure of pain control. Topical NSAIDs were associated with a reduction in the need for oral analgesia compared with control (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.34 to 0.61; low-certainty evidence). Approximately 4 out of 10 people in the control group used rescue analgesia at 24 hours. No data were available on the use of analgesia at 48 or 72 hours. There was no evidence from the included trials of an effect of topical NSAIDS on healing time and possible drug-related adverse events were low and balanced across intervention and control groups.

    Conclusions

    The findings of the included studies do not provide strong evidence to support the use.




    12 A multi-centre randomised feasibility study evaluating the impact of a prognostic model for management of blunt chest wall trauma patients: stumbl trial

    2017-11-23T07:59:42-08:00

    Introduction

    A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the Emergency Department (ED). A definitive randomised controlled trial (impact trial), is required to assess the clinical and cost effectiveness of the new model, before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design.

    Methods and analysis

    This feasibility trial is designed to test the methods of a multi-centre, cluster-randomised (stepped wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a five month period; in the initial period acting as the controls (normal care) and the second period, acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a six week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory).

    Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed.

    Ethics and dissemination

    Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Health Care Research Wales Research Permissions and the HRA have granted approval for the study. Patient recruitment commenced in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at Professional Meetings.




    13 Prophylactic antibiotics for penetrating injury: a review of practice at a major trauma centre, literature review and recommendations

    2017-11-23T07:59:42-08:00

    Background

    There is a lack of clarity regarding the use of prophylactic antibiotics for patients presenting with penetrating injuries. A structured literature review and review of penetrating injury records in an MTC was undertaken with a view to help guide clinical practice.

    Method

    Searches were conducted on Medline (1946–2017), Embase (1974–2017), and Cochrane (up to 2017) using key words pertaining to penetrating trauma, prophylactic antibiotics and infection. Cases of penetrating injury presenting to one MTC during 2015–2016 were extracted from the TARN database. Patient information (age, sex), injury details (ISS score, anatomical site, nature), antibiotic use in ED, and infectious outcomes were analysed.

    Results

    A 2012 systematic review by Bosman et al . included 11 RCTs, totalling 1234 patients with blunt and penetrating chest injuries requiring tube thoracostomy. Those that were given prophylactic antibiotics were less likely to develop empyema (OR:0.32), pneumonia (OR:0.51) and wound infections (OR:0.41) compared to placebo.

    A 2013 Cochrane meta-analysis on penetrating abdominal trauma found no RCTs comparing infection outcomes for prophylactic antibiotics vs placebo. No further trials have since been done. EAST guidelines (2012) recommend a single dose of prophylactic antibiotics for penetrating abdominal trauma. No relevant trials were found for penetrating soft tissue injuries.

    70 penetrating injuries for 2015–2016 were recorded on TARN, 40 of which were transfers from other hospitals. Half of the total injuries were stabbings, with the rest being shootings, falls and crush injuries. 62.5% of patients were given prophylactic antibiotics in ED. 83% of the remaining patients received antibiotics for another indication.

    Conclusions

    Strong evidence exists for the use of prophylactic antibiotics for chest wounds requiring tube thoracostomy. The Cochrane review concluded that there is no evidence base for prophylactic antibiotic use for penetrating abdominal trauma, with EAST recommendations based on weaker evidence.

    Drawing conclusions about infectious outcomes from TARN data is difficult due to low total numbers, differences in record-keeping for secondary transfers and a high proportion of patients with another requirement for antibiotics.

    For penetrating thoracic injury requiring chest drain there is evidence of benefit for prophylactic antibiotics, in other patients with penetrating injury due to the current lack of evidence, clinical judgement based on the circumstances of penetrating injury is recommended.




    14 Prediction of massive blood transfusion in battlefield trauma: development and validation of the military acute severe haemorrhage (MASH) score

    2017-11-23T07:59:42-08:00

    Background The predominant cause of preventable death from trauma is bleeding. Many patients need resuscitation with massive blood transfusion (MBT). In some theatres of military operation there is limited blood product availability and walking donor panels can be required. This study aimed to produce a tool to predict the need for MBT using information available on patient arrival at the ED for patients sustaining battlefield trauma. Methods A retrospective database analysis was undertaken using the UK Joint Theatre Trauma Registry (JTTR) to provide derivation and validation datasets. Regression analysis of potential predictive factors was performed. MBT was defined either as receiving 6 or more units of red blood cells (RBCs) in 4 hours or 10 units of RBCs in 24 hours. Predictive factors were analysed through multi-logistic regression analysis to build predictive models; sensitivity and specificity of these models was assessed, and the best fit models were analysed in the validation dataset. Results The derivation dataset was made up of 1298 casualties with a massive blood transfusion rate of 21.2% (n=275). The validation dataset contained 1186; MBT rate 6.7% (n=79). The majority of patients were young, male and with penetrating injury. Univariate regression analyses showing the predictive value of the variables within the MASH score are shown in table 1. A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital interventions. The test characteristics for three cut off thresholds for the rule are shown in Table 2 alongside the sensitivity analysis. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of MBT, with an AUROC of 0.93 (95% CI:0.91 to 0.95). Table 1Univariate regression analysis of variables included in the MASH score in the derivation dataset which predict the requirement for 6 units of pRBCs in 4 hours or 10 units of pRBCs in 24 hours Table 2Performance of the MASH score in derivation and validation datasets showing test characteristics for three values of the MASH score with 95% confidence intervals with sensitivity analysis for a score of 3 in the validation dataset Conclusions This study has produced the first military scoring system that uses clinical observations, injuries sustained and pre-hospital interventions to predict the need for MBT and therefore the requirement for an emergency donor panel in resource-limited environments. The MASH score has higher sensitivity and specificity than previous military prediction tools, and has the advantage of only using information which is rapidly available in the resuscitation bay. This is of importance to civilian practitioners with increasing possibility of major terrorist attacks. [...]



    15 A clinical decision tool for prescribing anti-platelet medication for patients with suspected acute coronary syndrome (PAM)

    2017-11-23T07:59:42-08:00

    Background The benefit of antiplatelet medication in confirmed acute coronary syndrome (ACS) is well established. In the Emergency Department (ED) diagnostic uncertainty may lead to over-treatment, with consequent risks (e.g., bleeding), or under-treatment, compromising clinical outcomes. Clinicians must subjectively balance the anticipated risks and benefits with their perceived probability of ACS in order to decide whether to prescribe these medications. We aimed to construct a clinical model to optimise and personalise recommendations for anti-platelet prescription in this context. Methods In stage 1 we conducted three full systematic reviews, which were registered with PROSPERO and conducted according to PRISMA guidelines. We searched MEDLINE, EMBASE and Cochrane to quantify the risks and benefits of ticagrelor, clopidogrel and nothing/placebo in comparison with aspirin alone. We extracted data for (a) the outcomes of cardiovascular death, acute myocardial infarction, stroke and major bleeding at 30 days and 12 months; and (b) weighted patient preferences (utilities) for each outcome or health state. In stage 2, we used those data to construct a probabilistic model that calculated the probability of each relevant outcome for patients with and without ACS. We assigned the patient-centred utilities identified to each clinical outcome, and calculated the net expected utility for each treatment strategy. Using that model, we calculated the probability of each outcome under conditions of diagnostic uncertainty. We then identified the threshold probability of ACS at which each treatment option became superior. Finally, we ran sensitivity analyses using both one-at-a-time (OATS) and Monte Carlo simulation with 10 000 cases. Results Systematic review identified three relevant original studies, and three sub-studies. After extracting data, we constructed two separate models, based on clinical outcomes after 30 days and 12 months. Aspirin alone led to greater net utility at probabilities below 7.4%, whereas treatment with ticagrelor led to greater net benefit when the probability of ACS exceeded 8.3% (figures 1 and 2). Sensitivity analyses including 10,000-fold Monte Carlo simulations demonstrated that the models were robust to a wide range of assumptions (figure 3). Figure 1Acute coronary syndrome risk thresholds of treatment strategy superiority. (Clopidogrel and ticagrelor treatment strategies included the use of aspirin at ACS treatment) Figure 2Net expected utility of anti-platelet therapy in 12 months combined outcome model Figure 3A monte carlo simulation (n=10,000) – net expected utility of anti-platelet therapy in 12 month combined outcome model – varying risk and utility outcomes Conclusion This work suggests that treatment with ticagrelor yields greater net benefit for patients when the probability of ACS exceeds 8.3%. This has potential to improve clinical outcomes when used alongside a prediction model, such as the Manchester Acute Coronary Syndromes (MACS) decision aid, which calculates each patient’s individual probability of ACS. The clinical and cost effectiveness of[...]



    16 Investigating the effects of under-triage by existing major incident triage tools

    2017-11-23T07:59:42-08:00

    Introduction Triage, the process of prioritising patients on the basis of clinical acuity, is a key principle in the effective management of a major incident. The overall effectiveness of the triage process is not only a balance between identifying those who need or don’t need a life-saving intervention, but also those who are under or over-triaged as either incorrectly needing/not needing intervention. The primary aim of this study was to describe the implications of under-triage using existing major incident triage tools, including the 2013 National Ambulance Resilience Unit (NARU) Sieve. The secondary aim was to describe the safety profile of the Modified Physiological Triage Tool (MPTT) in comparison to other triage tools, and to report mortality and identification of serious injury (AIS>3) in discrete AIS body regions. Methods A retrospective database review was undertaken using the UK Trauma Audit Research Network for all adult patients (>18 years) between 2006–2014. Patients were defined as Priority One using a previously published list. Using first recorded hospital physiology, patients were categorised by the MPTT, NARU Sieve and existing Triage Sieve. Data are presented as number (%) and median (IQR) as appropriate. Categorical data were analysed using a Chi Square test and continuous data with a Mann-Whitney U test. Results During the study period, 2 18 985 adult patients were included with 24 791 (19.5%) identified as Priority One. 70% were male, aged 51 years [33–71], ISS 16 [9–25] with road traffic collision the most common mechanism (34%). The MPTT demonstrated the lowest rate of under-triage (42.4%, p<0.001). Overall 30 day mortality for the Priority One cohort was 12.4%. Compared to existing methods, the MPTT under-triage population had significantly lower mortality (5.7%, p<0.001), identical to the overall study population. Patients under-triaged by the MPTT had significantly lower requirement for intubation, thoracocentesis and massive transfusion than both the NARU Sieve and Triage Sieve (p<0.001). Serious injuries to the thorax (47.0%) and head (27.4%) predominated, with the MPTT again significantly under-triaging fewer of these patients (p<0.001). Figure 1 Conclusion This study has defined the effects of and compared the implications of under-triage when different triage tools are used in the context of a major trauma population. The MPTT misses fewer severely injured patients, with fewer LSIs necessary in the under-triaged population. We suggest that the MPTT should be considered as an alternative to existing major incident triage tools. Table 1Frequency of interventions performed in the priority one cohort and patients under-triaged by the MPTT, UK NARU sieve and MIMMS triage sieve 2Defined as administration of 4 or more units of blood/blood products 3Defined as craniotomy, burr holes or removal of intracranial haemorrhage Table 2Frequency of severe injuries (AIS ≥ 3) by body region within the whole study population, the priority one cohort and in those under-triaged by the MPTT, the UK NARU sieve and [...]



    17 Exploring ambulance conveyances to the emergency department: a descriptive analysis of non-urgent transports

    2017-11-23T07:59:42-08:00

    Objectives An NHS England report highlighted key issues in how patients were initially navigating access to healthcare. This has manifested in increased pressure on ambulance services and emergency departments (EDs) to provide high quality, safe and efficient services to manage this demand. This study aims to identify non-urgent conveyances by ambulance services to the ED that would be suitable for care at scene or an alternative response. Design A retrospective analysis of emergency department data linked to initial pre-hospital call data (either ‘111’ or ‘999’) in 2014 in Yorkshire and Humber. A previously validated definition of non-urgent attendance at ED was adapted for pre-hospital use to identify all linked ambulance conveyances that had no ‘in-hospital’ specific investigations, treatments or follow up care during that episode. Linked data was used to identify clinical triage conditions at the time and source of call (999 or 111). Setting All 14 acute trusts (acute hospital and ambulance service) in Yorkshire and Humber. Outcome and measures The number of non-urgent attendances to ED which were conveyed by ambulance was examined in terms of age, time of arrival, initial triage (AMPDS) and final ED diagnosis. Figure 1ED final diagnosis for avoidable conveyances (n=65,360) Results 1,312,539 linked patient episodes were analysed which included ambulance service contact and hospital data. 4 04 348 (30.8%) of the total reported were transported by ambulance. Of all the linked conveyances, 65 360 (16.2%) were classed as non-urgent ED attendances. There were significantly increased odds of a non-urgent conveyance out of hours (OR:1.48; 95% CI:1.45 to 1.51). Of all conveyances of patients aged 16–34 (n=77,683), 24 443 (31.5%) patients were non-urgent. This compares with patients aged 75+ (n=150,668), in which 11 400 (7.1%) were considered non-urgent. 70.6% of the data was included for AMPDS analysis. This demonstrated the largest numbers of non-urgent conveyances (by code) came from falls (n=5277, 8.1%) and outside referrals such as ‘Healthcare Professionals’ (n=3983, 6.1%) and the ‘111 telephone service’ (n=9437, 14.4%). ED diagnosis analysis showed the highest proportion of patients were attending with minor injury and illness, and alcohol intoxication. Conclusions 16% of ambulance conveyances to ED in 2014 were non-urgent with around 1 in 3 patients under the age of 34 conveyed with non-urgent complaints. 1 in 5 patients had a non-urgent conveyance out of hours. AMPDS analysis identified target areas for intervention including referrals from other healthcare providers. Final ED diagnosis identified specific patient target areas including minor illness and alcohol intoxication. Figure 2 Figure 3Age of patients taken to ED by ambulance (avoidable) [...]



    18 How do public attitudes to automated external defibrillators affect their use in out-of-hospital cardiac arrest?

    2017-11-23T07:59:42-08:00

    Introduction

    Sudden cardiac death is one of the leading causes of mortality in the UK. The incidence of out-of-hospital cardiac arrest (OHCA) in the UK is approximately 30 000. The initial cardiac rhythm in these cases is often a ventricular tachyarrhythmia which requires electrical defibrillation. The efficacy of defibrillation is dependent on its timely use, with the odds of survival decreasing by up to 10% for every minute of delay. The use of AEDs has been shown to significantly improve neurologically intact survival in OHCA. Significant progress has been made regarding the provision of AEDs in public places but it is questioned whether sufficient public education has been undertaken in order to support this strategy. This study aims to explore the attitudes of the general public in order to inform public education strategies, increase AED use and ultimately improve survival of OHCA.

    Methods

    A questionnaire was devised and presented to a convenience sample of adult patients and their relatives presenting to the Emergency Department Urgent Care Centre at University Hospital Lewisham over a 3 month period from January-March 2017. Participants were asked about their age, educational background, previous resuscitation training and knowledge of AED. Those with correct knowledge of AEDs were also asked about their willingness to operate one and to give reasons if reluctant to use an AED in an OHCA.

    Institutional ethical approval was obtained.

    Results

    A total of 216 responses were obtained. 12 were excluded in the analysis as the questionnaires were not fully complete and thus 204 were included in the final data analysis. 32% of the study participants reported knowing about AEDs but only 23% correctly described its use. 19% of the study participants had both accurate knowledge and a willingness to operate an AED. 66% of those correctly describing AEDs and willing to use them had some form of resuscitation training. 6% of the study sample had no resuscitation training but correctly described AEDs and were willing to operate one.

    Common reasons for unwillingness to operate AEDs were fear of causing more harm, fear of doing it incorrectly, perceived danger of the equipment and lack of training.

    Conclusion

    The level of knowledge of AEDs is low amongst the general public. Majority of the study population who knew about AEDs had some degree of resuscitation training. Further research is required to ascertain how to translate knowledge into optimal use of AEDs in practice.




    19 Accuracy of biomarkers for venous thromboembolism in pregnancy: the diagnosis of pulmonary embolism in pregnancy (DiPEP) biomarker study

    2017-11-23T07:59:42-08:00

    Objective To estimate the accuracy of biomarkers for venous thromboembolism (VTE) in pregnant and postpartum women with suspected pulmonary embolism (PE). Design Observational cohort study augmented with additional cases with VTE. Setting Emergency departments and maternity units at eleven prospectively recruiting sites. Participants Pregnant or postpartum women presenting with suspected PE or diagnosed DVT. Interventions Research nurses/midwives collected a blood sample from women with suspected PE or diagnosed DVT and data relating to diagnostic imaging, treatment and adverse outcomes. Blood samples were centrifuged, stored and then transported to Guy’s St Thomas Trust for analysis. Main outcome measures Women were classified as having or not having VTE on the basis of diagnostic imaging, treatment and subsequent adverse outcomes. Primary analysis was limited to women with conclusive diagnostic imaging. Secondary analyses included women with clinically diagnosed or ruled out PE. Results Usable blood samples were taken from 18 women with diagnosed DVT and 310 women with suspected PE, of whom 18 had PE confirmed by imaging and 247 had PE ruled out after imaging and were included in the primary analysis. Mean biomarker levels only significantly differed between women with and without PE for Clauss Fibrinogen (p=0.007), ELISA D-Dimer (p=0.001), Innovance D-Dimer (p=0.004), Thrombin Generation Lag Time (p<0.001), Thrombin Generation Time to Peak (p=0.001) and Plasmin Antiplasmin (p=0.004). The AUC (95% CI) for each biomarker was APTT 0.669 (0.570 to 0.768), BNP 0.549 (0.453 to 0.645), C-Reactive Protein 0.542 (0.445 to 0.639), Clauss Fibrinogen 0.589 (0.476 to 0.701), ELISA D-Dimer 0.668 (0.561 to 0.776), Innovance D-Dimer 0.651 (0.545 to 0.758), MRproANP 0.524 (0.418 to 0.630), PF1 +2 00.562 (0.462 to 0.661), Plasmin-antiplasmin 0.639 (0.536 to 0.742), Prothombin Time 0.613 (0.508 to 0.718), Thrombin Generation Lag Time 0.702 (0.598 to 0.806), Thrombin Generation Endogenous Potential 0.559 (0.437 to 0.681), Thrombin Generation Peak 0.596 (0.478 to 0.715), Thrombin Generation Time to Peak 0.655 (0.541 to 0.769), Tissue Factor 0.531 (0.424 to 0.638) and Troponin 0.597 (0.499 to 0.695). ROC analysis showed that only thrombin generation lag time had any potential to rule out PE with sufficient sensitivity while achieving meaningful specificity, with sensitivity of 97% and specificity of 25% at the threshold that optimised sensitivity. Repeat analysis excluding women who had received anticoagulation was limited by the small number (n=4) who had PE. Conclusion Currently available biomarkers show little potential for aiding the diagnosis of suspected PE in pregnancy and postpartum. Figure 1 Figure 2 Figure 3 [...]



    20 Risk factors for admission at three, urban emergency departments in england: a cross-sectional analysis of attendances over one month

    2017-11-23T07:59:42-08:00

    Objective

    To investigate factors associated with unscheduled admission following presentation to Emergency Departments (EDs) at three hospitals in England.

    Design and setting

    Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (Site 1), and two district general hospitals (Sites 2 and 3). Variables included: patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included.

    Outcome measure

    The primary outcome for the study was unscheduled admission.

    Participants

    All adults aged 16 and over attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered.

    Results

    Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at Sites 2 and 3 (AOR relative to Site 1 for Site 2 was 1.89, 95% CI:1.74 to 2.05, p<0.001), and for patients of black or black British ethnicity (1.29, 1.16–1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the ‘four-hour target’ (a rule that limits patient stays in EDs to four hours in the NHS in England) emerged as a strong driver for admission in this analysis (3.61, 3.30–3.95, p<0.001).

    Conclusion

    This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED- and clinician-level behaviour relating to admission decisions. The four-hour target is a strong driver for emergency admission.




    21 Daily dynamic discharge - a whole system solution to ED crowding

    2017-11-23T07:59:42-08:00

    Introduction

    ED crowding is associated with increased mortality, poor staff and patient experience, an increased inpatient length of stay and poor compliance with the four-hour emergency access standard.1 Where crowding is caused by exit block, the focus needs to be on whole system patient management, reducing the temporal mismatch between admissions and discharges since at times of peak demand hospitals may become gridlocked until patients are discharged.

    In an attempt to tackle exit block, the Scottish Government Unscheduled Care Team have implemented the Daily Dynamic Discharge (DDD) approach, which aims to increase the number of inpatient discharges by 12 pm, thus enabling more timeous flow through the ED.

    Methods

    A series of meetings were held between the Unscheduled Care Team and the clinical and managerial staff of Dumfries and Galloway Royal Infirmary over a two-week period to train staff on implementing the elements of the Daily Dynamic Discharge approach. These included holding a daily whiteboard meeting with input from the multidisciplinary team, early determination of an Estimated Date of Discharge (EDD) for each patient, and conducting ‘golden hour’ ward rounds whereby the highest acuity patients were seen first followed by those who were expected to be discharged that day, thus increasing the number of discharges by 12 pm.

    Results

    Over a twelve-week period the average number of weekly discharges increased from 26.5 to 30.2, i.e., an average increase of 3.7 discharges per week. Average length of stay dropped from 6.8 days to 6.2 days, a saving of 0.6 days.

    The median discharge time was 32 min earlier once DDD had been implemented. Previously, a third (33%) of patients were discharged before 4 pm; after implementation, this rose to 44%.

    Discussion

    Emergency Department activity, and particularly crowding, is the barometer for the rest of the hospital, and the only way to guarantee that patients who require admission, get into the right bed, and in a timely way, is to ensure that the downstream wards discharge sufficient numbers early in the day to accommodate admissions from the ED.

    The DDD approach has been shown to be effective in increasing the number of discharges by 12 pm, smoothing the admission/discharge profile, and is now being adopted in other hospitals throughout Scotland.

    Reference

  • Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184(5):213–216.




  • 22 Emergency department litigation and coroners inquests: a ten year analysis

    2017-11-23T07:59:42-08:00

    Introduction

    The burden of litigation within the NHS should not be underestimated. Indemnity costs rise in response to the rising frequency and costs of claims, with recent changes to the discount rate projected to increase NHS Litigation Authority (NHSLA) costs by £1 Billion per year. Litigation also has a significant psychological impact on staff. This study represents the first examination of litigation and Coroner’s ‘Prevention of Future Deaths’ reports relating to emergency department care in the UK.

    Method

    Using the Freedom of Information (FOI) Act (2000) we submitted data requests to both the NHSLA and the Ministry of Justice (MoJ).

    The NHSLA provided data concerning ED litigation claims between 2006 and 2015 including:

  • Number of claims by year

  • Number of successful and unsuccessful claims by year

  • Number of settled claims

  • Cost of claims (including defence costs, claimant costs and damages awarded)

  • The MoJ provided data concerning PFD reports issued to EDs between 2006 and 2016. Data concerning PFD reports issued between 2012 and 2015 were extracted from the MoJ website. Data included:

  • Report date

  • Age and gender of the deceased

  • Report summary

  • Results

    The total number of ED litigation claims made between 2006 and 2015 was 10,040; 5745 (57.2%) resulted in a financial settlement. The number of claims successfully settled ranged from 382 in 2005/06 to 830 in 2014/15 with an upward trend throughout the decade. The mean cost of a successful claim was £114,029; increasing from £66 754 in 2005/06 to £1 41 027 in 2014/15, a 111% increase. Delay/failure in diagnosis was the most common cause for litigation (4318 [44.5%]) and PFD reports (15 [21%]).

    A total of 70 PFD reports were issued within the study period; there was no trend in the number of reports issued per year. The greatest number of reports were issued in 2014 (18), far exceeding any other year.

    Discussion

    Annual claim numbers have increased by 117% over the study period and mean claim cost has increased by 111% (far in excess of any rise expected due to inflation). Causation cannot be determined by this observational study, but potentially contributory factors include: the increasingly litigious nature of society in general; rising patient expectations and the worsening crisis in staff retention, recruitment and morale.

    This analysis of litigation patterns and PFD reports provides an insight that enables further focus on the underlying causes, subsequent improvement in patient care and a reversal of current litigation trends.




    23 Patient and staff perspectives on the reasons for increasing emergency department attendances

    2017-11-23T07:59:42-08:00

    Background/objectives

    An NHS England review recognised that demand for Urgent and Emergency Care is unsustainable. Health practitioners and policy makers are interested in understanding the reasons why patients with low acuity problems attend the Emergency Department (ED). This should, in turn, assist the development of interventions to reduce demand.

    We aimed to gain an understanding about the reasons for rising ED demand and to identify possible solutions.

    Methods

  • A self-report patient survey was administered to non-ambulance patients at 9 EDs across Yorkshire and Humber (Y and H) asking participants: reasons for attending the ED; awareness of alternative services; and perceptions of the suitability of other services to manage their health problem. Survey data was analysed descriptively and compared with two similar studies conducted in 1997 and 2006.

  • Semi-structured interviews were conducted with ED and Urgent Care staff (Consultants, Doctors, Nurses, Managers, General Practitioner) working in 9 EDs across Y and H. The interview topic guide was structured around: description of patients attending EDs and impact on demand; and current/future initiatives to deal with rising demand. The interviews were transcribed verbatim and analysed thematically using Framework Analysis.

  • Results

    481 surveys were completed. Increasing numbers of patients reported that a health professional advised them to attend the ED (31% in 1997 vs 50% in 2016). Awareness of alternative urgent care services had increased since 2006 but the perceived appropriateness of these services had decreased or stayed the same.

    Interviews were carried out with 25 ED and urgent care staff. Reasons for attendance at the ED were divided into patient-level reasons (e.g., people are more demanding of the healthcare system; poor health literacy) and structural-level reasons (e.g., difficulties accessing primary care; alternative healthcare services directing patients to the ED inappropriately). Our participants described a wide range of interventions divided into patient-level interventions (e.g., increasing patient education) and system-level interventions (e.g., streaming patients into appropriate services), but there was no clear consensus with regards to which interventions had had the greatest impact.

    Conclusion

    We found evidence of a rise in patients being referred to the ED by other healthcare services. This may be a reflection of the wider healthcare system under strain, thereby causing overspill into EDs. Future research is needed to design and test interventions that can lead to improvements in the system that are acceptable to patients, do not lead to increased demand, are cost-effective and lead to more sustainable working environments.




    24 An audit into the number of patients suffering out-of-hospital cardiac arrest that are resuscitated despite a high likelihood of futility

    2017-11-23T07:59:42-08:00

    Background

    For a significant number of patients suffering out-of-hospital cardiac arrest (OHCA) cardiopulmonary resuscitation (CPR) is likely to be futile and attempting it may be the wrong thing to do. Anticipatory care plans with do-not-attempt cardiopulmonary resuscitation (DNACPR) instructions exist to prevent this. Anecdotally we felt that many patients present to our Emergency Department (ED) with ongoing resuscitation which was not in their best interests. The aim of this study was to establish the proportion of patients arriving in our ED with ongoing CPR who had low, intermediate or high risk of futility.

    Methods

    The survival outcome and past medical history of patients with OHCA brought into the ED of the Royal Infirmary of Edinburgh in 2015 were extracted from hospital records. Indicators of general deteriorating health and clinical indicators of underlying life limiting conditions were used to populate the Supportive and Palliative Care Tool (SPICT). The SPICT score was used as a measure of likely CPR futility. A SPICT score of 0–2 meant low risk of futility, 3–4 intermediate risk and >5 a high risk.

    Results

    Of the 283 cases, 202 (71.4%) had a low risk of CPR futility; 46 (16.3%) an intermediate risk; and 35 (12.4%) were considered to be at high risk of CPR futility. In all low, intermediate and high risk categories, the commonest outcome was to be pronounced dead in A and E (55.4%, 73.9% and 71.4% respectively). For the low risk of futility group, a significant proportion (27.7%) survived to hospital discharge, whereas patients in the intermediate and high risk groups rarely survived with only 2.17% and 2.86% respectively discharged from hospital. Of the low, intermediate and high risk patients, 11.4%, 91.3% and 100% respectively had one or more significant underlying comorbidities.

    Conclusions

    Our results suggest that community DNACPR implementation in Edinburgh is suboptimal, with many patients resuscitated and transported to the ED with ongoing resuscitation despite a high likelihood of futility. It is unclear what is required to improve this situation. Possible avenues for improvement may be more anticipatory care planning in the community, better recording of the outcomes of key conversations with patients and carers, or more consistent implementation of these plans by Ambulance Service responders. We plan further work to establish how this system can be changed to serve patients and their families better.




    25 Organ donation in emergency departments: an analysis of best practice

    2017-11-23T07:59:42-08:00

    Introduction The 2015 RCEM End of Life Care best practice guideline highlighted the need for organ and tissue donation to be a usual part of end of life care in the Emergency Department (ED). NICE guideline states that all deaths meeting defined clinical triggers in the ED (in practice – mechanical ventilation, plan to withdraw life sustaining treatment, death expected) should prompt timely referral to organ donation services. Any family discussion in the ED regarding organ donation should be held collaboratively with a specialist nurse for organ donation (SNOD). What is the evidence in UK EDs that this is always the case? Methodology The NHS Blood and Transplant Potential Donor Audit, carried out by specialist nurses in organ donation, audits every death aged 80 years and under in UK Emergency Departments and Intensive Care Units. Data from the Potential Donor Audit was analysed and compared across the 12 Regional NHSBT teams. Results Almost all deceased donors in the UK are admitted to hospital via an Emergency Department (ED). The number of patients dying in UK EDs aged under 80 years of age and under (1 st April 2015 to 31 st March 2016) is variable across the country and not directly correlated with population. Patients dying in ED, who meet criteria for referral is equally variable across the UK (Range 1% Scotland – 3.9% Eastern). PDA data (1 April 2016 – 31 March 2017) reveals that 284 patients died in ED meeting referral criteria but only 47% were referred (Range 22%–65% across the 12 regions). Longer 4 year analysis (1 st April 2012 – 31 st March 2016) demonstrated that up to 16% of these patients are on the Organ Donor Register. Of the 125 families approached in the ED (1 April 2016 – 31 March 2017) only 67% involved a SNOD (Range 0%–100% across the 12 regions). Discussion In 2017, with the endorsement of RCEM, NHS Blood and Transplant published Organ Donation and the Emergency Department: A Strategy for Implementation of Best Practice. The strategy promotes identification and referral of potential organ donors in the emergency department and collaborative approach of their families when withdrawal of treatment is planned in the Emergency Department. Most importantly it is emphasised that organ donation should be firmly established as a usual part of end of life care irrespective of the location of the patient. Figure 1Audited deaths in ED by organ donation region 1st april 2015 to 31st march 2016 Figure 2Died in emergency department meeting PDA referral criteria 1st April 2016 to 31st March 2017 Figure 3Families approaches regarding organ donation in the ED 1st April 2016 to 31st March 2017 [...]



    26 Protocol for the upcoming study: patient input monitoring of pain in the emergency room: novel electronic log (PIMPERNEL): a randomised controlled trial of an electronic pain score display in adults in the emergency department

    2017-11-23T07:59:42-08:00

    Background

    Patient surveys and research have shown that Emergency Department attendees do not receive adequate analgesia. Pain monitoring has not been automated and usually involves a member of staff asking the patient to rate their score with no continuous record, often no specific place to record it and no automated alarm system for scores outside accepted parameters. Few patients have regular monitoring of their pain and our own preliminary research showed that over one week only 58% of patients with moderate to severe pain had a second or subsequent score recorded.

    Equipment

    A small pain monitoring display has been developed at the University of Leicester and acts as an electronic version of the 11 point numerical rating scale. Data are transmitted to a tablet through a wireless connexion. PIMPERNEL (Patient Input Monitoring of Pain in the Emergency Room: Novel Electronic Log) is a feasibility study testing this for the first time.

    Objectives

    The primary objective is to determine the feasibility of studying the effect of an electronic pain monitoring display on the pain experienced by emergency care patients. Secondary objectives include determining whether patients use the display, whether pain ratings correlate with routine records, how pain changes over time, whether patients use the display for reasons other than pain, which potential stratification factors may be useful for a subsequent multi-centre study and whether analgesia prescription changes. We will also obtain patient and staff feedback.

    Inclusion criteria

    Adults, initial pain score 5 or more, likely to be staying for at least 2 hours, able to consent and understand English.

    Study procedure

    We aim to recruit 200 patients (100 per arm) from the emergency department at Leicester Royal Infirmary. All patients will use the display. This is a parallel group, two arm superiority trial with a 1:1 allocation ratio. Patients will be randomised to have their pain score on display (intervention) or hidden (control). Blinding is not possible. The display beeps every 15 min to remind patients to enter their pain score. Treatment will not be constrained by study protocol and will depend on the judgment of the treating clinician. The study will continue for up to 6 hours to allow time for the first dose of analgesia to wear off. Data collection will cease when the patient leaves the department. Questionnaires will be given to participants and the staff nursing them.




    27 The DiPEP (Diagnosis of PE in Pregnancy) study: can clinical assessment, d-dimer or chest x-ray be used to select pregnant or postpartum women with suspected PE for diagnostic imaging?

    2017-11-23T07:59:42-08:00

    Objective

    To determine whether clinical features (in the form of a clinical decision rule) or d-dimer can be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.

    Design

    Observational cohort study augmented with additional cases.

    Setting

    Consultant-led maternity units participating in the UK Obstetric Surveillance System (UKOSS) and emergency departments and maternity units at eleven prospectively recruiting sites.

    Participants

    198 pregnant or postpartum women with diagnosed PE identified through UKOSS and 324 pregnant or postpartum women with suspected PE from prospectively recruiting sites.

    Interventions

    Data were collected relating to clinical features, elements of clinical decision rules, d-dimer measurements, diagnostic imaging, treatment for PE and adverse outcomes.

    Main outcome measures

    Women were classified as having or not having PE on the basis of diagnostic imaging, treatment and subsequent adverse outcomes. Primary analysis was limited to women with conclusive diagnostic imaging. Secondary analyses included women with clinically diagnosed or ruled out PE.

    Results

    The primary analysis included 181 women with PE and 259 without. Most clinical features showed no association with PE. The only exceptions were number of previous pregnancies over 24 weeks (p=0.017), no varicose veins (p=0.045), no recent long haul travel (p=0.006), recent surgery including caesarean section (p=0.001), increased temperature (p=0.003), low oxygen saturation (p<0.001), PE-related chest x-ray abnormality (p=0.01) and other chest x-ray abnormality (p=0.001).

    Clinical decision rules had areas under the receiver-operator characteristic curve ranging from 0.577 to 0.732. No clinically useful threshold for decision-making was identified for any rule. The sensitivities and specificities of d-dimer were 88.4% and 8.8% using the standard laboratory threshold and 69.8% and 32.8% using a pregnancy-specific threshold.

    Conclusions

    Clinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.




    28 Are we measuring what we think we are measuring? Qualitative research exploring the role of the 0-10 pain score within the adult emergency department

    2017-11-23T07:59:42-08:00

    Objectives and background

    The assessment of pain in the emergency department (ED) is difficult but important for appropriate management of pain. Guidelines for the management of acute pain in the ED worldwide advocate using numeric rating scales such as the 0–10 pain score as tools to ensure consistency of documenting patient’s pain, and this is mandated at initial assessment in many EDs. Studies of interventions to improve pain management in the ED indicate that whilst the inclusion of mandatory pain scoring within interventions may improve documentation of pain, there was mixed evidence as to whether this resulted in improvements in provision of analgesia. As part of a wider study looking at barriers and enablers to pain management in the ED, we explored how pain scoring was used in the ED.

    Methods

    Qualitative data were collected within 3 case study EDs in the UK. Data comprised 143 hours of non-participant observation, 37 ED staff interviews and 19 patient interviews. Data were analysed using thematic analysis.

    Results

    Observation showed variation in how the pain score was documented between EDs. Some staff documented the score directly reported by the patient, whilst others documented a score they formulated using a combination of physiological signs, behavioural signs and presence of a ‘known’ painful condition. ED staff appeared to understand the score as an absolute measure used to guide analgesia requirements or triage categories rather than a relative measure used to document changes in pain levels. Even when documenting patient reported scores, they perceived patient reported scores to be inconsistent with their own assessment of the patients pain level, particularly where this could lead to patients being managed under a higher triage category or receiving stronger analgesia than ED staff considered appropriate. Staff documented pain scores that were appropriate for the treatment they planned to provide, rather than the scores reported by the patient, in particular when the pain score was used as a tool for auditing appropriate pain management.

    Conclusions

    The pain score appeared to have parallel but misaligned roles: to assess patient pain and ED staff practice. ED staff faced conflict between the need to record pain to ensure accountability of pain management, and recording pain to reflect the patient’s report. The role of the pain score needs to be reviewed in order for pain scoring to improve the patient experience of pain management in the ED.




    29 Has the licensing ACT 2003 affected levels of violence in England and Wales? A systematic review of hospital and police studies

    2017-11-23T07:59:42-08:00

    Background

    Population-level legislation has been implemented in many countries to try and address alcohol misuse and related harms, including assault. Most violent incidents in the UK are alcohol-related, with alcohol misuse accounting for a substantial proportion of Accident and Emergency Department attendances. The Licensing Act 2003 aimed to reduce alcohol-related crime and disorder by abolishing set closing times and giving local authorities control over premises licensing in England and Wales. Concerns were raised, however, that greater availability of alcohol would lead to increased consumption and violence. This review examines primary research from hospital and police settings to evaluate whether the implementation of the Act in 2005 reduced or increased violence rates in England and Wales.

    Methods

    We performed an inclusive systematic review of the major biomedical databases. We included original research that evaluated changes in violence rates before and after the implementation of the Licensing Act, including hospital- and police- defined measures for this primary outcome. Our secondary outcome was whether there was change in temporal distribution of violent incidents after implementation of the Act.

    Results

    We identified 184 studies. 15 studies were included. The evidence was of overall poor quality, with the majority of included studies being uncontrolled before-after studies. 8 of these studies were conducted in the hospital setting, and 7 were from the police setting. Overall, 7 studies found reduced violence rates after implementation of the Licensing Act, 3 found increased rates, and 5 found no significant change. A subset of 9 papers analysed temporal distribution of violent incidents, 8 finding evidence of temporal displacement of assaults further into the early hours of the morning.

    Conclusion

    This is the most complete analysis to date of the effects of the Licensing Act on violence. There is no evidence for the Act having a significant or consistent effect on community violence rates, either in emergency departments or policing. There is consistent evidence from both hospital and police settings of a proportional increase in late-night violence since the implementation of the Act.




    30 Do nice guys finish last?

    2017-11-23T07:59:42-08:00

    Emergency medicine is widely recognised as an intense specialty. Interruptions are known to derail thoughts, increasing cognitive load and result in longer periods before deep thought is re-established. Although approachability and warmth are regarded as important factors in clinicians we wondered what impact these characteristics had on the number of interruptions.

    Methodology

    A team of 6 medical students were trained in the use of abespoke tool to record shop floor activities. Over 4 months we conducted 100 hours of minute by minute time and motion study of emergency medicine consultants during their clinical shifts, and noted how often they were interrupted. At the end of shifts the assessors were asked a set of qualitative questions on the behaviour and attitudes of the consultants. These questions were completed in seclusion and in an anonymous format, to minimise the chance of bias/influence.

    Questions included

    ‘How friendly was the consultant with other staff?’ ‘How friendly was this consultant with patients?’ And, ‘How would you rate this consultant’s ‘general positivity’?’

    We then assessed whether consultants that scored ‘higher’ inthese areas were more likely to be interrupted. Our hypothesis was that consultants who were more friendly were less intimidating for juniors and nurses to approach with questions, and so may suffer from an increase in cognitive load due to being interrupted and questioned more frequently than consultants who were felt to be less approachable.

    We found that consultants who scored 1(highest) in friendliness had an average of 7.38 interruptions per hour, compared to consultants who scored 3 or greater, who had an average of 3.59.

    Conclusions

    Our average interruptions were close to those found in previous publications (between 6 and 9 interruptions per hour), however there was a large amount of inter-consultant variability, with one consultant during one shift being interrupted over 12 times per hour on average. If the results of this study are replicable, then it may raise questions about how best to manage this extra cognitive load. Although some may argue that being seen as slightly less friendly has an advantage in the reduction of interruptions, this may come at a cost to patient safety. There is clearly a fine balance to be made.

    Figure 1

    Average interruptions per hour by friendliness score




    31 The quality improvement QIP - improving multidisciplinary staff engagement with quality improvement in the RVH emergency department

    2017-11-23T07:59:42-08:00

    In recent years the RVH Emergency Department (ED) had been under intense pressure and public scrutiny. This led to a demoralised workforce who had become disengaged with quality improvement (QI). QI projects had become an exercise in data collection with little focus on improving care for patients. Two consultants undertook training in QI and then decided to develop a QI project aiming to empower staff and embed QI as daily practice. An ED QI steering group of interested multidisciplinary members was formed and devised an improvement plan to increase staff engagement with QI. The steering group secured funding for a subscription to the Institute of Healthcare Improvement (IHI) online open school. This was made available to 50 staff and was used to increase knowledge of QI methodology. An aim of 250 open school modules completed by August 2017 was set. This total was surpassed in June 2017, amounting to over 330 hours of QI training undertaken in staff’s own time. To date 13 staff members have achieved IHI Certificates in Quality and Safety. We designed a series of projects which were linked with the Trust Improvement plan. The QI teams are all multidisciplinary with medical and nursing staff from different grades involved in each as well as input from other professionals such as pharmacy, physio and clerical/admin staff. Figure 1 Through the delivery of this project the ED team’s enthusiasm for QI has been reinvigorated. We have demonstrated improvements in clinical standards such as pain management where a project was undertaken, which has seen a 4 fold increase in the number of patient’s who sustain a fractured hip receiving the gold standard treatment of fascia iliaca nerve block. We have shown improvements in communication with the ‘Unfinished Symphony’ project demonstrating significantly better ED/GP written handover correspondance and the ‘What’s in a name’ project decreasing inter-specialty conflict during the referral process. We have also increased efficiency with senior review for Ambulance patients and subsequent significant decrease in waiting times. A recent project targeting the waste associated with unnessecary triage blood tests is showing promising early results. Figure 2 The ED improvement team have endeavoured to improve the environment for staff by developing a ‘Grrr to Great’ board, through which staff are empowered to highlight problems but are also tasked with developing solutions. We have also increased accessibility of QI data by producing a QI update board and displaying data openly and transparently in the department. Figure 3 [...]



    32 Do low-risk patients with non-cardiac chest pain prefer early discharge after rapid rule-out in the emergency department?

    2017-11-23T07:59:42-08:00

    Background There has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED). Previously, such patients would have been admitted to a hospital bed for observation and delayed biomarker testing. While the drive to implement rapid rule-out strategies comes from healthcare providers, there has been little assessment of patient perspectives on early discharge, in what is known to be a high-anxiety presentation. We aimed to explore patient perspectives on the acceptability of early discharge strategies. Methods This prospective quantitative survey was conducted on consecutive patients admitted from the ED to a short-stay ward for evaluation of suspected cardiac chest pain at a single centre in the UK. All patients were discharged within 36 hours with a diagnosis of low-risk chest pain. The written questionnaire was designed with closed answer questions with responses standardised along a 5-point Likert scale and was completed by patients upon discharge. Ethical approval was obtained. Results Of 739 patients requested to complete the survey, 278 (37.6%) responded. Mean age 56.6 years (SD 13.4), 263/278 (94.6%) White British, mean length of stay 15.5 hours (SD 6.6), 6/278 (2.2%) had a major adverse event (MACE) at 30 days. Responders were more likely to be female than non-responders (49.6% vs 37.5%, p=0.001), otherwise groups were matched in age, cardiac risk factors, length of stay and the presence of MACE (p>0.05 for all). Table 1Summary of patients’ responses from questionnaire The majority of patients, 197/278 (70.8%) would have been satisfied or very satisfied with early discharge directly from the ED, with 36/278 (13.0%) expressing dissatisfaction with a proposed rapid rule-out strategy. However, 249/277 (89.9%) of responders were reassured by admission to the ward and 112/273 (41.0%) felt they could not have spent any less time in hospital. Through binary logistic regression we analysed potential predictors of dissatisfaction with early discharge, these were sex, age, severity and type of pain at presentation, previous ischaemic heart disease, family history and found none were significant. Conclusions Most patients would be satisfied with a rapid rule-out strategy, however, it should be acknowledged that patients receive reassurance from hospital admission and over 10% of patients would be dissatisfied with discharge direct from ED. Improved patient information and shared decision making is required when rapid discharge strategies are incorporated into practice. [...]



    33 Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

    2017-11-23T07:59:42-08:00

    Background

    Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.

    Methods

    We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (viaEBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.

    Results

    The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were under-powered with sample sizes of 1028–1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.

    Table 1

    Conclusion

    Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.




    34 A systematic literature review of the pre-hospital lessons identified following mass casualty deliberate bombing incidents

    2017-11-23T07:59:42-08:00

    Background Since the end of World War II, there has been an emergence of explosives used amongst civilian populations resulting in mass-casualty incidents. The development of pre-hospital medical systems, worldwide, has resulted in an increased response at these incidents. However, information about the pre-hospital medical response is sparse and not collated. This review aimed to collect and appraise the literature on the pre-hospital management of mass-casualty bombing incidents. The primary objective was to identify and discuss the common themes highlighted as problems in the pre-hospital medical response. The secondary objectives reviewed the injury patterns in victims and psychological impacts on pre-hospital responders. Methods A systematic literature search on the PubMed, SCOPUS and Web of Science databases took place. It included literature published from the 1 st of January 2000 to April 3rd 2017, with the last search performed on April 3rd 2017. Literature was included if it offered description, analysis, reflection or review of the bombing incidents. Figure 1The minimum number of recorded deaths and injuries from 11 deliberate mass casualty bombing incidents (note: two simultaneous marauding terrorist firearm attack and bombing incidents excluded) Figure 2Percentage of included literature identifying the following themes as problems in the pre-hospitals medical response Results 1345 articles were found, with 54 included in analysis. 13 mass-casualty bombing incidents were described. Two of these included marauding terrorist firearm attacks (MTFA). In the 11 bombing-only incidents the death of 592–642 people and injury of 3,842–5229 more is described, with a further 301 deaths and 604 injuries from bombings with MTFA attacks. Quality appraisal showed a variation in reporting among incidents and a lack of uniform reporting. Conclusions Functioning and reliable communication, alongside regular training exercises with other emergency services, is important in the pre-hospital response. This is aided through accurate triage, in a safe area, to ensure even casualty distribution. A visible and established command and control enables scenes to be led effectively. Access to suitable and adequate supplies of equipment fosters improvement in patient outcomes. Awareness of secondary devices, as well as chemical, radiological and nuclear exposure, is vital in ensuring responder safety. A variety of injury patterns was found. Finally, psychological complications and support systems amongst pre-hospital responders varied. [...]



    35 To pan-scan or not to pan-scan? Further analysis of the tarn database 2012-2017

    2017-11-23T07:59:42-08:00

    Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven. We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s). Methods We analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases. Results 15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1. Table 1Patients characteristics Propensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2. Table 2Modelling morality using pan-scan as exposure factor The results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS). Conclusion The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in Engla[...]



    36 Frailty flying squad: an emergency department focussed acute care of the elderly service DR genevieve robson, royal united hospital NHS foundation trust

    2017-11-23T07:59:42-08:00

    Introduction The over 75 s make up 20% of our ED attendances. The greatest increase has been in the over 85 s. This very elderly cohort are more likely to be frail and are 10X more likely to require admission than 20–40 year olds and once in hospital have longer stays. There is evidence that multidisciplinary care and early Comprehensive Geriatric Assessment (CGA) improves outcomes for older patients, reducing readmissions, long term care, greater satisfaction and lower costs. The aim of this project was to improve the acute care provided to our older patients at the Front Door of the hospital. Methodology 3 month pilot project underpinned by Big Room Quality Improvement methodology. The Frailty Big Room meets weekly and includes input from clinicians, QI experts and a data analyst. This project was driven by the following aims: Frailty Flying Squad to see as many older±frail patients referred for admission as close to the front door as possible. CGA at the front door with discharge planning from first review MDT approach Expedited discharge or transfer to other services from ED. Review following day to make sure management plans being followed through or discharge without ward teams having to become involved. Frailty Flying Squad Team: 2 Medical Nurse Practitioners Physiotherapist Consultant geriatrician Key Performance Indicators: Length of Stay Readmission within 30 days of initial review Results 355 patients were seen. 168 (47%) of patients were over 85 and the median Rockwood frailty score for the whole cohort was 6. 209 patients were ED referrals and 85 were GP referrals for admission. 237 (67%) patients were seen in ED, 49 in MAU and 7 in ED obs. During the pilot period, 97 patients who had been referred for admission were discharged direct from ED. 56 (16%) of patients had zero length of stay. A low number (9.4%) of patients were readmitted within 30 days. Figure 1LOS Figure 2Length of stay for the > 85s 2016 and 2017 compared Conclusion A multidisciplinary Acute Care of the Elderly Team predominantly based in the Emergency department can provide effective early Comprehensive Geriatric Assessment; facilitating discharge home from the Emergency Department, reducing length of stay for those admitted and reducing readmission rates within 30 days. [...]



    37 Routine testing of salicylate levels in overdose patients: still needed?

    2017-11-23T07:59:42-08:00

    Introduction and aims Overdose is a common presentation in Emergency Departments (EDs) across the UK. Salicylate poisoning is potentially fatal; however it is becoming increasingly uncommon in the UK. This may be due to restriction of pack sizes in over the counter medicines as well as the use of aspirin as an analgesic being superseded by other NSAIDs, particularly ibuprofen. In conjunction with clinical features of salicylate toxicity, measurement of plasma salicylate concentration can help guide management. Many EDs routinely test for salicylate levels in all cases of overdose, and yet this may not be necessary as recommended by the NPIS. This study aims to assess the cost implication of over testing for salicylate in overdose patients, as well as the prevalence of salicylate poisoning in three EDs in the West Midlands. Method A multicentre retrospective case note study was undertaken from January 2016 to March 2017. Data were collected from 3 EDs in the West Midlands. Cases of overdose where salicylate levels were requested were identified in conjunction with biochemistry departments, and information gathered regarding age, gender, nature of overdose, patient weight, GCS, clinical features of salicylate toxicity and plasma salicylate concentration. Results Across the three centres, 4296 requests were made for salicylate levels during the study period. Of those samples, just 115 detected any salicylate at all (2.7%). The majority of these samples had levels just over limit of detection. This is in keeping with the previous observation that salicylate poisoning is uncommon. Of the 4296 samples sent, 3651 were not indicated, i.e., no clinical features, patient alert, and denied aspirin overdose. With the cost of plasma salicylate concentration analysis being £4.58 (average over the 3 sites) there is a potential cost saving of £16 721 per year. Conclusions Salicylate poisoning appears to be uncommon among patients presenting with overdose. Results show that it is likely that EDs are over testing for salicylate levels. In accordance with NPIS advice, there is no need to measure salicylate levels in conscious overdose patients who have no features of toxicity and deny salicylate ingestion. This may have cost implications, allowing departments to save money by reducing the amount of routine salicylate testing overall. [...]



    38 A comparison of two interventions in the treatment of severe ankle sprains and distal fibular avulsion fractures: a patient perspective

    2017-11-23T07:59:42-08:00

    Stable ankle injuries are highly prevalent in Emergency Departments across the UK. Appropriate management to enable patients to experience a smooth recovery and prevent chronic ankle instability or reoccurrence is a priority. Current literature states that stable ankle fractures and severe ankle sprains can be successfully managed with the below knee plaster or the aircast brace and crutches. The functional brace has proved to be clinically effective in several reports. There has however, been no research to measure patient satisfaction levels between these two treatments. An experimental, mixed method approach to the researching of this issue was performed in a busy, central London Emergency Department; a randomised controlled trial undertaken to compare the two devices and quantitative and qualitative data collection by means of a tailored questionnaire to determine patient satisfaction. Thirty nine patients were recruited during hospital attendance over 9 months. Patients were requested to complete the questionnaire 7 days into their treatment via post; stamped addressed envelopes were provided. Telephone interview was adopted as a secondary measure when postal responses failed. The primary outcome measured was patient satisfaction levels regarding comfort of the device, pain relief, daily activities, sleep, work, care of dependents and social life measured by use of a likert scale; ranging from very unsatisfactory to very satisfactory. The null hypothesis is that there is no significant difference in satisfaction levels between the two devices. Data was analysed using the unrelated t test. 31 responses were obtained; 16 participants with avulsion fractures to the distal fibular and 15 severe ankle sprains, 16 allocated to the ankle brace and 15 to the plaster. The findings demonstrate that there were statistically significant higher patient satisfaction levels in patients treated with an aircast brace than with the plaster cast. Using a probability level of 0.01, the critical value was 2.756, the t value 4.996; therefore the null hypothesis was rejected. The main indicators contributing to these findings were in the levels of comfort, daily activities, sleep work and social life. Overall it appears that patients preferred treatment with the aircast brace. Both forms of treatment were clinically equally effective in this study. Evidence indicates that our current department guidelines may need to be re-evaluated. In addition, this a study focused on patient-centred care. The questionnaire [...]



    39 Violence intervention and prevention in emergency rooms: the viper study

    2017-11-23T07:59:42-08:00

    Background Nearly half a million people are killed each year as a consequence of intentional injury and many more seriously injured. Information sharing by Emergency Departments with local government for crime prevention purposes has previously been described as an effective, cost effective, low cost and low risk intervention for tackling community violence. The UK Department of Health and the Home Office support this process known as the Information Sharing to Tackle Violence (ISTV) program. In 2007, we implemented ISTV and have witnessed a substantial reduction in assault related attendances. We aimed to examine the epidemiology of our assault victims over the introduction period. We hypothesised a priori that there would be reductions in the proportions of patients who attended at the weekend and late at night, reductions in the proportions of young adult males, and reductions in the more seriously injured patients. Methods We extracted all the cases of assault from our patient administration system between the 1 st of January 2005 and the 31 st of December 2014 and analysed the data using Poisson regression. To estimate the trend over the 10 year period, we used indicator variables for each year (other than 2005 which was treated as the reference category) to allow for non-linearity. Deviance tests of the models were used to assess whether the inclusion of the interaction terms improved model fit. When there was evidence of statistically significant interactions, we re-ran the model looking at the rate of change over time separately for each strata of the effect modifier. Results Over the study period, the rate of emergency department presentations following an assault decreased up until 2014, at which point it was 37% lower (IRR=0.63; 95% CI:0.57 to 0.69) than in 2005. There were greater reductions for presentations on weekends (IRR=0.57; 95% CI:0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI:0.62 to 0.83); presentations with no hospital follow-up (IRR=0.51; 95% CI:0.45 to 0.56) versus those leading to either an inpatient (IRR=1.05; 95% CI:0.84 to 1.31) or outpatient (IRR=1.23; 95% CI:0.93 to 1.64) follow-up over the 10 year period. Conclusions The ISTV program in this single ED has been associated with substantial reductions in violence related presentations. This effect is most marked in presentations at the weekend, younger patients and in those who appear to be least seriously injured. [...]



    40 ED crowding: the acceptability of dysfunction

    2017-11-23T07:59:42-08:00

    Background Crowding in the Emergency Department is internationally recognised as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of crowding, including increased length of stay, mortality and cost per admission. Crowding is typically a manifestation of a hospital at full capacity and its main contributor is the practice of boarding patients in the ED. Therefore, a functioning flow system is advised to ease the burden. Different predictive tools/algorithms assess the degree of crowding. The National Emergency Department Overcrowding Scale (NEDOCS) is used effectively in other countries but has not been validated in Ireland. Aims To assess crowding in a major Irish teaching hospital over a three week period at regular time periods using the NEDOCS. To look at the time from decision to admit to ward bed availability in order to improve flow through the department. Staffs perception of crowding was assessed at a random single time point. Methods Application of the NEDOCS score in the Emergency Department along with the use of internal Patient Administration System (PAS) to track patient movement through the ED. Results During the three week period, the NEDOCS score was frequently at level 6 (dangerously overcrowded) or level 5 (severely overcrowded) (see figure 1). Emergency patient registrations peaked between 1000 hours to 1300 hours whereas the peak admission time to wards was between 1900 hours and 2300 hours. At a random time point, Universal staff perception of crowding in the department was perceived as ‘It’s a nice day’. However the NEDOCS level was 4 (overcrowded) suggesting significant crowding. Figure 1 Figure 2Average reception activity per 24 hour Conclusion Our Hospital is operating at a consistent level of crowding that can negatively impact on patients. Access to inpatient beds is available late in the day, creating a time lag between decision to admit and transfer to ward. Staff perception did not correlate with NEDOCs score, possibly reflecting a conditioning and acceptance of staff to crowding. Discussion We plan to validate the NEDOCS score in an Irish Emergency Department. Crowding is a significant issue in the Irish Healthcare setting. The ‘40% of inpatient beds by 11 am’ needs to be adopted by our hospital. Our study suggests that our emergency staff accept the dysfunctional as the norm. [...]



    41 Simultaneous trauma patients in emergency departments: a difference in mortality?

    2017-11-23T07:59:42-08:00

    Background

    The presentation of multiple simultaneous trauma patients in an Emergency Department, is likely to place significant stress and strain on trauma care resources. Currently there is limited data available to understand the impact simultaneous trauma demands on patient outcomes. For the purposes of this project we define simultaneous trauma as occurring when there is more than one TARN qualifying major trauma patient within an Emergency Department at any one time. We hypothesise that with increasing numbers of simultaneous trauma patients a relative increase in mortality will be seen.

    Methods

    Data was obtained from the Trauma Audit and Research Network for calendar years 2010–2015 on TARN qualifying trauma patients presenting directly to Emergency Departments. Simultaneous patients were identified and the data was categorised by total number of TARN qualifying patients within the Emergency Department (range 2–6). Patient characteristics were obtained which included sex, age, Glasgow Coma Score and Injury Severity Score (ISS). A standardised comparison using a stratified W statistic (Ws) was conducted to assess mortality and the Charlson co-morbidity score was used to assess morbidity outcomes.

    Results

    Results were obtained for 2 07 094 of which 66 734 (33.7%) patients were eligible simultaneous patients.

    The distribution of simultaneous patients was 2 patients, 24.9% (51,466), 3 patients, 6.7% (13,820), 4 patients, 1.7% (3,539), 5 patients, 0.3% (671), and 6 patients, 0.01% (185). The median age was 61 (IQR 39.5–80.3), 55.7% of patients were male, median ISS score was 9 (IQR 9–16) and median GCS was 15 (IQR 15–15)

    Isolated and simultaneous patients, regardless of number of patients, showed no difference in W statistic.

    The average mortality for all patients was 7.2% (range 6.5%–7.6%).

    Conclusion

    The impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on overall mortality rate.

    Table 1

    Further work planned will understand the impact of multiple trauma patients on length of stay and time to CT/operating theatre.




    42 Assessing factors affecting the quality of chest compressions during training for laypersons using a novel CPRCARD

    2017-11-23T07:59:42-08:00

    Objective

    The quality of cardiopulmonary resuscitation (CPR) has been shown to affect the survival of out-of-hospital cardiac arrest cases (OHCA). There are various individual factors that can affect the quality of chest compression. We aimed to determine if age, gender and physical attributes (height, weight and BMI) affected the quality of chest compressions administered by laypersons during training.

    Design and methods

    The CPRcard is a novel device that captures and provides real-time visual feedback on chest compression quality through a 2 metre display. We analysed data from our layperson CPR and AED training sessions from October 2015 to November 2015. Measurement parameters were adequate depth, adequate rate and flow fraction. Adequate depth was the percentage of total chest compressions with depth 5 cm. Adequate rate was the percentage of compression with rate between 100–120 chest compressions per minute. Flow fraction is the percentage of time chest compressions were performed without more than a 3 s pause. An adequate flow fraction target was >80%.

    Results

    77 participant’s data were analysed. 35% were male and 65% were female, with majority (34%) being 35–44 years old. The mean height was 1.63 m±0.10 m, mean weight 61.4 kg ±14.0 kg and mean BMI 23±4 kg/m2. Median adequate rate decreased significantly with age (p value=0.02). Median adequate depth and flow time showed no association with age (p=0.56, p=0.46 respectively). Males managed a significantly better median adequate depth (82.0% vs 56.0%, p value=0.01). There was no significant difference in chest compression quality with height, weight and BMI.

    Conclusions

    Overall, at least 1 parameter of chest compression quality decreased with age, and was better in males than females. A possible application of these results is to have differences in training methods for different ages and sexes, targeting parameters that they are weaker at.




    43 Management of acute low back pain in the ED: a systematic review

    2017-11-23T07:59:42-08:00

    Study objective

    There is no consensus on the management of low back pain in the ED and evidence suggests that these patients are likely to receive unwarranted imaging and inappropriate opioid prescription.

    The purpose of this study is to review the available literature pertaining to the clinical management of acute low back pain in the ED.

    Methods

    The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were observed during this review.

    Trials were included if the population studied were adults with acute low back pain in an emergency setting. All diagnostic tests and therapeutic interventions were evaluated.

    Methodological quality and risk of bias was appraised using the Downs and Black checklist.

    Results

    19 articles were identified including 1896 patients that were sub-grouped according to management.

    In the pharmacological subgroup corticosteroids were effective in patients with radicular pain, NSAIDs were as effective as other medication with less adverse events, Phenyramidol was not superior to placebo, promethazine and morhpine combined was not more effective than morphine alone and ketamine was no more effective than morphine but had a worse adverse effect profile.

    In the emergency transport group TENS and active warming both showed effects in reducing pain, anxiety and heart rate.

    In the physical therapy management group less pain and greater satisfaction were reported.

    In the adjunct interventions group showed a trend towards pain reduction in the use of heat/ice packs and short term pain relief in acupuncture and auricular acupuncture.

    Conclusions

    More high quality trials are needed to determine an evidence-based management protocol for the treatment of acute low back pain in the ED.




    44 Quantifying the 5 year mortality of frequent attenders to the emergency department

    2017-11-23T07:59:42-08:00

    Introduction

    Frequent Attenders (FA) to Emergency Departments (ED) are a vulnerable population which we perceive to have a high morbidity and mortality. ED clinicians find this population challenging and they are at risk of being stigmatised. There has been little published work in the UK quantifying the risk of death in this population. Here we aim to quantify the 5 year mortality of this population and identify key risk factors.

    Methods

    We identified a cohort of frequent attenders, defined as attending the ED 5 times or more between 1/4/2010 and 31/3/2011. We followed these patients via their electronic patient record from Cambridge University Hospital which is linked to the NHS spine.

    Overall mortality for the population has been calculated and we will produce a censored Kaplan-Meier survival estimate to account for patients we have been unable to follow up. Using a cox regression model we will analyse the impact of the chosen variables (age, sex, continued number of attendances to ED, and presence of a major physical or psychological illness or alcohol abuse) on mortality.

    Initial results

    (pending full statistical analysis)

    5 year mortality for the entire cohort was 24% and when limited to 16–65 year olds 5 year mortality was 11%. There will be a full risk factor analysis of this data available.

    Conclusion

    Frequent Attenders to Addenbrooke’s ED have a risk of death much greater than the normal population. A large proportion of the patients who died were very elderly and so 5 year mortality is less surprising but may suggest a need for further community care involvement to reduce ED attendance.

    The crucial finding is that the risk of death for adult FAs between the age of 16–65 is much higher than would be expected of the normal population. This indicates a need to treat this population with increased care.




    45 Patient evaluation of trauma service

    2017-11-23T07:59:42-08:00

    Patient Experience of the Trauma System (PETS) Trauma care is highly organised, time critical medicine. Changes to patient management in trauma care are often the result of Random Control Trials, and expert opinion following rigorous evaluation of the evidence. Highly efficient, injury focused care is required to achieve the best outcomes for patients. One area that has not been researched so thoroughly however, is the patient experience of trauma care. As evidence already suggests that patients with high stress levels have poorer outcomes, we wanted to investigate the patient perception of the trauma system. We were particularly interested to find out if there were any areas where patient anxieties could be reduced or eliminated. Methodology A ten-person qualitative study was initially conducted to test for feasibility and reproducibility. The methodology involved semi-structured interviews investigating outcome measures such as the patient’s perception of being looked after, biggest concerns and understanding of care, among others. Interviews were undertaken by a medical student and a Foundation Year 2 doctor (at the end of the Emergency Medicine block, post sign-off) trained in the methodology. The initial study was carried out over one month in early 2017 and involved adult patients (>18 years) admitted via the trauma care pathway who were Glasgow Coma Score 15/15. Interviews took place within 48 hours of admission in the Emergency Department (prior to transfer), the observation ward or the extended care trauma unit. Barriers to patient interviews included: severity of injuries; patient refusal; language proficiency and patient recollection (some had no recollection of being in resus). Despite this we managed an initial sample of 10 patients, with rich data. Following on from the pilot study we have made some amendments to our questions and have conducted a further set of 20 interviews. Conclusions A significant proportion of patients have concerns during trauma care that they feel unable to voice. This has the potential to increase their stress levels and have an adverse impact on their recovery. The concerns are varied and not always predictable, often unrelated to the injury. Thus we feel there may be patient benefit from the use of a single open question towards the end of the primary s[...]



    46 Testing of the 'always events approach to improve the patient experience in the emergency department

    2017-11-23T07:59:42-08:00

    Aims This project aimed to identify issues patients would like to see improved when interacting with the Minor Injuries Unit (MIU) and as a result generate measurable and feasible Always Events (AEs) based on patient feedback that can be implemented via a Quality Improvement (QI) process. We then looked to assess and improve on the delivery of the agreed AEs to enhance MIU patient experience. Methods AEs were identified by using a short semi-structured survey questionnaire with a free text response section from 45 patients. Patients were asked what should always happen in the ED. Iterative thematic analysis identified information provision and explaining how the department worked as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented to address this issue. Improvement was assessed via convenience sampling of patient questionnaires using a five-point bipolar Likert scale and free text responses which were compared to a set of baseline results via run charts to examine impact of each intervention. A total of 300 patients completed questionnaires throughout the baseline and intervention periods. Results Baseline results stood at 80% for patient satisfaction regarding information provision, rising to 88% by the end of the poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions stood at 83% in the baseline sample before rising to 86% throughout the poster and video intervention. Composite survey results rose from a baseline level of 82.2% to 86.3% for the poster intervention and 88.8% by the end of the video intervention stage. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period. Figure 1 Figure 2 Discussion Implementing the AE approach in the MIU has had a positive effect on patient experience. The poster intervention had the greatest impact on enhancing patient understanding. Our study indicated that direct information provision from staff was sufficient for patients and improvements in responses were due to the project interventions. Next steps should be to further implement the video in the department via inclusion on the patient Wi-Fi homepage and waiting room television to maximise the impact of the vid[...]



    47 Systematic review and meta-analysis of analgesic efficacy and safety profile of single injection fascia iliaca compartment blocks in the acute pre-operative pain management of hip fractures

    2017-11-23T07:59:42-08:00

    Background It is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age. Objectives Determine the analgesic efficacy and safety profile of single injection FICB performed in the pre-operative period for acute pain management in adult patients with traumatic hip fractures compared to other forms of analgesia. Methods MEDLINE, EMBASE, Cochrane and CINAHL were independently searched to identify randomised controlled trials (RCTs) in English. Patients aged >18 years old who have suffered an isolated traumatic hip fracture (proximal femoral fracture) and received single injection FICB pre-operatively were included. No date restriction was applied and key journals and articles were scrutinised to include studies not identified by the primary search. Results Out of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=–1.82 (95% CI:–2.26 to –1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias. Figure 1 Figure 2 Conclusions FICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia. [...]



    48 Calpol: are we overdosing on blood tests?

    2017-11-23T07:59:42-08:00

    Background In February 2012, the Commission on Human Medicines recommended lowering the paracetamol toxicity treatment threshold for all patients. Children between one month and six years of age are physiologically distinct and metabolise paracetamol differently, making them less prone to toxicity. Furthermore, overdose in early childhood is almost exclusively accidental, as opposed to predominately deliberate self harm seen in adults and adolescents. As a result, the use of the new 75 mg/kg ingestion threshold for young children would appear to be of unproven benefit, and is substantially lower than the threshold used in other countries. Aim To establish the sensitivity and negative predictive value of using a 150 mg/kg ingestion threshold to identify hepatotoxicity in children one month to six year old group with paracetamol overdoses. Method Retrospective case review. Potential cases were identified by filtering an electronic Patient Management System for a discharge diagnosis of ‘accidental ingestions and poisonings’ over the period 1 st January 2012 to 19th October 2016 (57 months). ED documentation was reviewed to identify cases of paracetamol ingestions by children under the age of 6 years. Those with intentional harm, known staggered ingestions over 1 hour or under one month age (corrected for gestation) were excluded. Clinical notes and laboratory data were reviewed and, data parameters collated using a standardised proforma. Ingested doses were estimated, where possible, by subtraction methods. In some cases, the ingestion time was revised according to the time that the child was previously seen prior to the ingestion. A composite outcome for hepatotoxicity was used consisting firstly of the current UK standard treatment threshold (100 mg/L line on paracetamol toxicity nomogram) together with any evidence of biochemical hepatoxicity or clinical features of potential hepatotoxicity at any subsequent ED attendances over the next 7 days. Results The final cohort consisted of 165 individual patient ingestions. A 150 mg/kg ingestion threshold had a sensitivity of 100.0% (95% CI:47.5 to 100.0) for hepatotoxicity, with a negative predictive value of 100% (95% CI:97.5 to 100.0). Conclusion This retrospective[...]



    49 Paediatric traumatic cardiac arrest - the development of a treatment algorithm

    2017-11-23T07:59:42-08:00

    Introduction Paediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA. Methods A modified consensus development meeting was held. Statements discussed in the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three round online Delphi study. Those participants completing the first round of the Delphi study were invited to attend. 19 statements relating to the diagnosis, management and futility of paediatric TCA were discussed in small groups. After five minutes the key points from the small groups were presented to the whole audience. Subsequently, using electronic voting devices, each participant anonymously recorded their agreement with the statement using ‘yes’, ‘no’ or ‘don’t know’. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm. Results 41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively. Figure 1 Figure 2 Conclusion In attempt to standardise our approach to the management of paediatric TCA and to[...]



    50 How can informal support impact child PTSD symptoms following a psychological trauma?

    2017-11-23T07:59:42-08:00

    Background An estimated 20% of children who present to hospital emergency departments following potentially traumatic events (e.g., serious injuries, road traffic accidents, assaults) will develop post-traumatic stress disorder as a consequence. The development of PTSD can have a substantial impact on a child’s developmental trajectory, including their emotional, social and educational wellbeing. Despite this, only a small proportion will access mental health services, with the majority relying on informal sources of support. Parents, in particular, are often the primary source of support. However, it remains unclear what types of parental responses may be effective, and parents themselves report experiencing uncertainty about the best approach. To address this gap in knowledge, we examined the capacity for specific aspects of parental responding in the aftermath of child trauma to facilitate or hinder children’s psychological recovery. Method We conducted a longitudinal study of 132 parent-child pairs, recruited following the child’s experience of trauma and subsequent attendance at one of four regional emergency departments. At an initial assessment, within 1 month post-trauma, we examined how parents appraised and responded to their child following the event, using both questionnaires and direct observations. Child-report questionnaires were used to assess PTSD symptom severity at 1 month, and at a follow up 6 months later. Children also reported on their own appraisals of the trauma and their coping behaviours, which were considered as potential mediators between parental support and later child symptoms. Results Controlling for relevant covariates and initial PTSD symptoms, parent negative appraisals of the trauma and encouragement of avoidant coping in children were associated with higher child-reported PTSD symptoms at 6 month follow-up. There was some evidence that children’s own trauma related appraisals and coping styles mediated these effects. Conclusion Findings indicate that children’s social support can influence their post-trauma psychological outcomes. That parenting was associated with 6 month PTSD, even after controlling [...]



    51 Paediatric emergency clinicians are rarely exposed to non-airway critical procedures: a predict/PERN study

    2017-11-23T07:59:42-08:00

    Background Recent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians. Objective To determine the recent performance or supervision, and confidence for various paediatric critical non-airway procedures by senior paediatric emergency clinicians. Design/methods Web based survey of senior paediatric emergency clinicians regarding performance, supervision, and confidence relating to critical non-airway procedures in children aged 0–18 years. The survey was distributed through Paediatric Emergency Research Networks (PERN) in the UK and Ireland, USA, Canada, Europe, South America, Australia and New Zealand. Results 1602 clinicians responded to the survey, with an overall response rate of 65%. 1508 (94%) respondents reported their most recent non-airway procedural experience. In the last 12 months, 979 (64%) had personally inserted an intraosseous line, 283 (19%) a central venous line, and 265 (18%) an arterial line. In the same time period, 962 (64%) had performed CPR, 190 (13%) had performed needle thoracostomy, 245 (16%) had performed tube thoracostomy, 380 (25%) had performed DC cardioversion or defibrillation, and 57 (4%) had performed transcutaneous pacing. 18 (1%) had performed pericardiocentesis, 19 (1%) a venous cutdown, and 21 (1%) ED thoracotomy. More than 70% of respondents had never supervised or performed pacing, pericardiocentesis, venous cutdown or ED thoracotomy. 332 (22%) and 348 (23%) had never performed or supervised insertion of a central venous line or arterial line respectively. Procedural confidence for intraosseous lines and CPR was high, while confidence increased with increasing patient age for central venous access and arterial lines. ED thoracotomy, pericardiocentesis and venous cutdown had the lowest frequency of respondents reporting confidence in performing the procedure. Conclusion[...]



    52 Loop-mediated isothermal amplification PCR (LAMP) for the rapid identification of invasive meningococcal disease in the emergency department

    2017-11-23T07:59:42-08:00

    Background Despite successful vaccination programmes meningococcal disease (MD) remains the leading infectious cause of septicaemia and death in children in the UK and Ireland.1,2 The early diagnosis of MD significantly improves outcomes with reduced morbidity and mortality.1,2 The early stages of MD are often indistinguishable from a simple viral illness making an early positive diagnosis of MD difficult.1 Hibergene have developed a commercially available bedside Loop-mediated isothermal AMPlification PCR (LAMP-MD) test that is a highly sensitive 0.89 (95%CI 0.72–0.96) and specific 1.0 (95%CI 0.97–1.0) for identifying children with invasive MD (4) (figure 1). Figure 1 Aims The aims of this RCEM funded study were: Assess the ease of use and suitability for the ED Determine the time taken to perform the test Independently verify LAMP-MD performance against TaqMan quantitative PCR. Method The LAMP-MD was assessed for practicality and ease of use within the ED including an assessment of training needs, footprint and health and safety requirements. For verification of the Hibergene LAMP-MD analyser and assay we used dry nasopharyngeal swabs sent for viral screening. Additional verification was undertaken using N. meningitidis genomic DNA spiked over a range of concentrations. This included serotypes A, B, C, W, X and Y and a dilution series to determine the limit of detection. All samples were then analysed using real time TaqMan qPCR. Results The LAMP-MD analyser was easy to use and could be accommodated in the ED The mean time for detection of Meningococcal DNA was 14.01 min Detection of meningococcal serogroups A, B, C, W, X and Z was confirmed The detection limit for dry nasopharyngeal swabs was below 2 genomic copies per µl No non-specific amplification was observed in 17 randomly selected negative clinical swabs The LAMP-MD assay was 100% sensitive and specific relative to real-time TaqMAN PCR. Conclusion LAMP-MD is a practical, rapid point of care test that can reliably detect all Meningococcal serotypes in less than 15 min. Funding has been secured to perform a PERUKI supported study[...]



    53 Piloting patch - providing assessment and treatment for children at home - and piecing together what works

    2017-11-23T07:59:42-08:00

    Aims PATCH is a pilot acute community children’s nurse led service delivering assessment and treatment for children at home who are moderately unwell and might otherwise be admitted to hospital or attend Paediatric Emergency Department (PED). Children are referred by PED or GP and followed up via telephone support and home visits depending on clinical need for duration of acute illness. Methods Pilot year funded by Imperial Charity. Using evaluation to build business case for sustained commissioned service. Phase 1 Sept 2016 – May 2017 : reduced short stay admissions and re-attendances to PED for common mild-moderate respiratory conditions e.g., viral wheeze, bronchiolitis. Phase 2 from May 2017 : piloting direct GP referrals to PATCH team to evaluate impact in reducing attendances to PED for children needing further assessment or support beyond GP consultation, and enabling families to manage common acute conditions at home. Using QI methodology, Model for Improvement we developed a driver diagram and used real-time PDSA cycles to capture our learning and inform small iterative changes of service development. Process mapping and world cafe style events were held with local community nurses, health visitor leads, GPs and commissioners to co-design referral pathways and explore more widely how PATCH fits into the whole urgent care system. Figure 1 Parental feedback evaluated via semi structured interviews. Results Activity – Appendix 1 Phase 1 – Concentrated on respiratory conditions from PED. Total 188 referrals in first 7 months. Bronchiolitis 45%; viral wheeze 37.5%; asthma 7%; lower respiratory tract infections 5.4%. Figure 2 50% of patients received home visits and telephone consultations; 50% only telephone support. Successes: Cost effective – Appendix 2 73 acute admissions avoided, costing c£400 per/night 97 PED re-attendances prevented at £117 per attendance. Projected cost avoidance within acute care provider £3 27 640 pa. Estimated cost of service £2 84 000 pa. Positive feedback and reported health s[...]



    54 Paediatric traumatic cardiac arrest in England and Wales a 10 year epidemiological study

    2017-11-23T07:59:42-08:00

    Introduction Traumatic cardiac arrest (TCA) has traditionally been described as futile, with poor outcomes. Reported survival rates vary widely, with higher rates observed from mechanisms leading to a respiratory cause of traumatic cardiac arrest (e.g., drowning and hanging). Currently there is little evidence regarding outcomes following TCA in children. The primary aim of our study was to describe 30 day survival following TCA. Secondary aims were to provide an analysis of injury patterns (severe haemorrhage or traumatic brain injury), describe the functional outcome at discharge and to report the association between survival and interventions performed. Methods Using the Trauma Audit and Research Network (TARN) database, we conducted a population-based analysis of all paediatric (<18 years) trauma patients presenting to hospitals in England and Wales between 2006–2015. Patients with TCA in the pre-hospital setting and/or in the Emergency Department were included. Those without a GCS entry were excluded. Basic demographics are reported as number (%) and median (interquartile range), as appropriate. Survival odds ratios (95%CIs) and Chi Square tests were used during statistical analysis. Results During the study period, 21 710 paediatric patients were included in the database with 129 (0.6%) sustaining traumatic cardiac arrest and meeting study inclusion criteria (1.3%). The majority had a pre-hospital traumatic cardiac arrest (103 (79.8%)). Overall, 62.8% were male, aged 11.7 years (3.4–16.6), ISS 34 (25–45) and 110 (85.3%) had blunt injuries with road-traffic collision the most common mechanism (56.6%). 123 (95.3%) had severe haemorrhage and/or traumatic brain injury. Table 1 Table 2 Table 3 Overall survival was 5.4% (95% CI:2.6 to 10.8) with 7 cases surviving to 30 days. ‘Pre-hospital only’ traumatic cardiac arrest (13.0%) had a significantly higher survival than ‘pre-hospital and Emergency Department’ traumatic cardiac arrest (1.8%), (p=0.04). Those with injuries to the thorax predominated the severe haem[...]



    55 'Mini Sim - innovative bite sized simulation teaching in a busy childrens emergency department

    2017-11-23T07:59:42-08:00

    Emergency Medicine requires a highly skilled workforce who are passionate about delivering excellent patient care. Shift patterns linked with the ever increasing numbers of patients who attend Emergency Departments puts strain on educating the workforce and fostering team togetherness. Our objective in devising and instigating the ‘Mini Sim’ programme was to embed regular in-situ simulation training to enhance the learning of all staff within our Emergency Department team, building a highly trained workforce to deliver excellent care within the remit of our busy department. The whole team is involved including junior nurses, senior nurses and all tiers of junior doctors including foundation, general practice and senior ED trainees (including Grid). ‘Mini Sim’ takes place on a weekly basis, every Tuesday morning from 0930–1000. This timing is to ensure maximum participation from all staff. The setup is a fifteen minute simulation (one nurse, one junior doctor, one senior doctor) followed by fifteen minutes of debrief. The format includes an assessment of the participants confidence prior to ‘Mini Sim’ in the subject being practiced. This is rated on a numerical scale from 1 (being not confident at all) to 5 (being completely confident). The topics chosen are based on feedback from trainees and nurses on clinical skills they feel under confident in, (e.g., pelvic binder application, rapid sequence induction, sickle cell crisis), clinical incidents which have occurred around the Trust (e.g., seizures and access to benzodiazepines), National Patient Safety Alerts (e.g., phenytoin toxicity), protocols (e.g., abducted child, rapid tranquilisation for the acutely disturbed adolescent) , governance issues (e.g., blocked tracheostomy, resuscitation room rebuild) and competencies linked to RCEM objectives. The ‘Mini Sim’ then takes place in situ within the ED resus, ED main department or our short stay observation ward which is under the auspices of the Children’s Emergency Department usi[...]



    56 Manipulation and reduction of paediatric forearm fractures using Es-ketamine in a paediatric emergency department - a 5 year study

    2017-11-23T07:59:42-08:00

    Background Forearm fractures are the most common paediatric injury presenting to A+E.1,2 Literature supports safe and effective treatment of these injuries in A+E using a variety of sedation methods, including ketamine.3,4 The Paediatric Orthopaedic Trauma Snapshot (POTS) study showed that only 35% of A+Es nationally allow manipulation of these injuries in the department. Methods A retrospective analysis was undertaken of all patients presenting with fractures of the forearm between January 2012 to December 2016 who were treated with reduction and manipulation in the Alder Hey A+E department using Es-ketamine. Pre and post manipulation radiographs were reviewed, and fracture angulation measured pre and post reduction. Results A total of 151 patients were included with an average age of 8.5 years. 3 Salter Harris Type I, 16 Salter Harris Type II, 54 metaphyseal fractures, 44 distal third diaphyseal, 31 middle third diaphyseal and 3 proximal third diaphyseal were noted. 3 patients were lost to follow up after initial post reduction films. 11 patients required operative intervention following initial reduction. At one week follow up a further 5 patients were deemed to be of an unacceptable position requiring definitive operative management. No fractures slipped beyond 1 st week post procedure. A successful reduction, with improvement in lateral angulation, was achieved in 90% (133/148) of patients. The average pre-reduction lateral angulation was 23.7 degrees, post reduction was 4.6 and at final review was 0.3 degrees. At final follow up average 32 days all patients had clinical and radiological union. Discussion Es-Ketamine has been established as a safe method of sedation in paediatrics. Es-Ketamine allows same day discharge thus improving patient journey and leading to about £63 000 savings annually. Conclusions With adequate and appropriate training, the majority of simple radius and ulna fractures can be reduced and definitively treated safely and effectively using Es-ketamine in the emergency depart[...]



    57 Support for suddenly bereaved parents in the emergency unit

    2017-11-23T07:59:42-08:00

    The Paediatric Emergency Unit at the University Hospital of Wales provides care for over 33 000 children per year. There was no provision in place to support suddenly bereaved families. Staff felt that we could improve the services provided to families who’s children sadly died in the unit. The aim was to provide immediate support for the suddenly bereaved families by working in partnership with local Charity 2 Wish Upon a Star. Together we created a Standard Operating Procedure (SOP) that consisted of a checklist and pathway allowing us to refer relatives for immediate physical and emotional support. The pilot ran for 12 months offering support and counselling tailored to each individual family. The bereaving process begins in the emergency department. When a child had died families were given the to Wish Upon a Star memory boxes which contained physical support including two cuddly elephants, one to follow the patient and one for the parent/carer to keep and hand and foot print kits. As well as written booklets giving practical information on the next steps such as post mortems and funerals- these often very difficult questions to ask and answer. And about the charity itself. Once consent was gained by the staff, the families details were shared with the immediate support worker at the charity who would contact them within 24 hours. The initial 12 months trial had 18 paediatric deaths, 17 of which took up the support offered to them. The informal feedback we gained was positive from both staff and families. Our relationship with the charity has enabled us to feedback to the individual nurse involved, thus improving staff well being. Due to the success of this pathway it has been extended to include young adults up to the age of 25 years. The model has also been rolled out across critical care in UHW and is now being used in all emergency department in Wales. This innovative partnership offers immediate support to bereaved families across Wales which has improved care and serv[...]