bluuebunny/crossref_metadata_2025 huggingface dataset:
Cohort study of growth patterns by gestational age in preterm infants developing morbidity
Authors: Klevebro S , Lundgren P , Hammar U , Smith L E , Bottai M , Domellöf M , Löfqvist C , Hallberg B , Hellström A
Published: November 2016

Objectives

To examine differences in growth patterns in preterm infants developing major morbidities including retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC) and intraventricular haemorrhage (IVH).

Study design

Cohort study of 2521 infants born at a gestational age (GA) of 23–30 weeks from 11 level III neonatal intensive care units in USA and Canada, and 3 Swedish population-based cohorts.

Outcomes

Birth weight and postnatal weight gain were examined relative to birth GA and ROP, BPD, NEC and IVH development.

Results

Among infants with a birth GA of 25–30 weeks, birth weight SD score and postnatal weight were lower in those developing ROP and BPD. Infants developing ROP showed lower growth rates during postnatal weeks 7–9 in the 23–24 weeks GA group, during weeks 4–6 in the 25–26 weeks GA group and during weeks 1–5 in the 27–30 weeks GA group. Infants with BPD born at 27–30 weeks GA showed lower growth rates during postnatal weeks 3–5. Infants with NEC had lower growth rates after postnatal week 6 in all GA groups, with no significant differences in birth weight SD score. IVH was not associated with prenatal or postnatal growth.

Conclusions

In this cohort study of extremely preterm infants, we found that the postnatal growth pattern was associated with morbidities such as ROP, BPD and NEC as well as with gestational age at birth.
Cohort study investigating the relationship between cholesterol, cardiovascular risk score and the prescribing of statins in UK primary care: study protocol
Authors: Finnikin Samuel , Ryan Ronan , Marshall Tom
Published: November 2016

Introduction

Risk scoring is an integral part of the prevention of cardiovascular disease (CVD) and should form the basis for the decision to offer medication to reduce cholesterol (statins). However, there is a suggestion in the literature that many patients are still initiated on statins based on raised cholesterol rather than a raised CVD risk. It is important, therefore, to investigate the role that lipid levels and CVD risks have in the decision to prescribe. This research will establish how cholesterol levels and CVD risk independently influence the prescribing of statins for the primary prevention of CVD in primary care.

Methods and analysis

The Health Improvement Network (THIN) is a database of coded primary care electronic patient records from over 500 UK general practices. From this resource, a historical cohort will be created of patients without a diagnosis of CVD, not currently receiving a prescription for statins and who had a lipid profile measured. A post hoc QRISK2 score will be calculated for these patients and they will be followed up for 60 days to establish whether they were subsequently prescribed a statin. Primary analysis will consist of predictive modelling using multivariate logistic regression with potential predictors including cholesterol level, calculated QRISK2 score, sociodemographic characteristic and comorbidities. Descriptive statistics will be used to identify trends in prescribing and further secondary analysis will explore what other factors may have influenced the prescribing of statins and the degree of interprescriber variability.

Ethics and dissemination

The THIN Data Collection Scheme was approved by the South-East Multicentre Research Ethics Committee in 2003. Individual studies using THIN require Scientific Review Committee approval. The original protocol for this study and a subsequent amendment have been approved (16THIN009A1). The results will be published in a peer review journal and presented at national and international conferences.
Evaluation of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care: a qualitative study
Authors: Roets-Merken Lieve M , Vernooij-Dassen Myrra J F J , Zuidema Sytse U , Dees Marianne K , Hermsen Pieter G J M , Kempen Gertrudis I J M , Graff Maud J L
Published: November 2016

Objectives

To gain insights into the process of nurses’ changing perceptions when trained to implement a self-management programme for dual sensory impaired older adults in long-term care, and into the factors that contributed to these changes in their perceptions.

Design

Qualitative study alongside a cluster randomised controlled trial.

Setting

17 long-term care homes spread across the Netherlands.

Participants

34 licensed practical nurses supporting 54 dual sensory impaired older adults.

Intervention

A 5-month training programme designed to enable nurses to support the self-management of dual sensory impaired older adults in long-term care.

Primary outcomes

Nurses’ perceptions on relevance and feasibility of the self-management programme collected from nurses’ semistructured coaching diaries over the 5-month training and intervention period, as well as from trainers’ reports.

Results

Nurses’ initial negative perceptions on relevance and feasibility of the intervention changed to positive as nurses better understood the concept of autonomy. Through interactions with older adults and by self-evaluations of the effect of their behaviour, nurses discovered that their usual care conflicted with client autonomy. From that moment, nurses felt encouraged to adapt their behaviour to the older adults’ autonomy needs. However, nurses’ initial unfamiliarity with conversation techniques required a longer exploration period than planned. Once client autonomy was understood, nurses recommended expanding the intervention as a generic approach to all their clients, whether dual sensory impaired or not.

Conclusions

Longitudinal data collection enabled exploration of nurses’ changes in perceptions when moving towards self-management support. The training programme stimulated nurses to go beyond ‘protocol thinking’, discovering client autonomy and exploring the need for their own behavioural adaptations. Educational programmes for practical nurses should offer more longitudinal coaching of autonomy supportive conversational skills. Intervention programming should acknowledge that change is a process rather than an event, and should include self-evaluations of professional behaviours over a period of time.

Trial registration number

NCT01217502, Post-results.
Effect of support group peer facilitator training programmes on peer facilitator and support group member outcomes: a systematic review
Authors: Delisle Vanessa C , Gumuchian Stephanie T , Kloda Lorie A , Boruff Jill , El-Baalbaki Ghassan , Körner Annett , Malcarne Vanessa L , Thombs Brett D
Published: November 2016

Objective

Peer facilitators play an important role in determining the success of many support groups for patients with medical illnesses. However, many facilitators do not receive training for their role and report a number of challenges in fulfilling their responsibilities. The objective of this systematic review was to evaluate the effects of training and support programmes for peer facilitators of support groups for people with medical illnesses on (1) the competency and self-efficacy of group facilitators and (2) self-efficacy for disease management, health outcomes and satisfaction with support groups among group members.

Methods

Searches included the CENTRAL, CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science databases from inception through 8 April 2016; reference list reviews; citation tracking of included articles; and trial registry reviews. Eligible studies were randomised controlled trials (RCTs) in any language that evaluated the effects of training programmes for peer facilitators compared with no training or alternative training formats on (1) competency or self-efficacy of peer facilitators, and (2) self-efficacy for disease management, health outcomes and satisfaction with groups of group members. The Cochrane Risk of Bias tool was used to assess risk of bias.

Results

There were 9757 unique titles/abstracts and 2 full-text publications reviewed. 1 RCT met inclusion criteria. The study evaluated the confidence and self-efficacy of cancer support group facilitators randomised to 4 months access to a website and discussion forum (N=23; low resource) versus website, discussion forum and 2-day training workshop (N=29). There were no significant differences in facilitator confidence (Hedges' g=0.16, 95% CI −0.39 to 0.71) or self-efficacy (Hedges' g=0.31, 95% CI −0.24 to 0.86). Risk of bias was unclear or high for 4 of 6 domains.

Conclusions

Well-designed and well-conducted, adequately powered trials of peer support group facilitator training programmes for patients with medical illnesses are needed.

Trial registration number

CRD42014013601.
End-of-life experiences of mothers with advanced cancer: perspectives of widowed fathers
Authors: Park Eliza M , Deal Allison M , Yopp Justin M , Edwards Teresa P , Wilson Douglas J , Hanson Laura C , Rosenstein Donald L
Published: November 2016

Objective

Despite the importance of parenting-related responsibilities for adult patients with terminal illnesses who have dependent children, little is known about the psychological concerns of dying parents and their families at the end of life (EOL). The aim of this study was to elicit widowed fathers’ perspectives on how parental status may have influenced the EOL experiences of mothers with advanced cancer.

Subjects

344 men identified themselves through an open-access educational website as widowed fathers who had lost a spouse to cancer and were raising dependent children.

Methods

Participants completed a web-based survey about their wife's EOL experience and cancer history, and their own depression (Center for Epidemiologic Studies Depression Scale, CES-D) and bereavement (Texas Revised Inventory of Grief, TRIG) symptoms. Descriptive statistics, Fisher's exact tests, and linear regression modelling were used to evaluate relationships between variables.

Results

According to fathers, 38% of mothers had not said goodbye to their children before death and 26% were not at all ‘at peace with dying.’ Ninety per cent of widowed fathers reported that their spouse was worried about the strain on their children at the EOL. Fathers who reported clearer prognostic communication between wife and physician had lower CES-D and TRIG scores.

Conclusions

To improve EOL care for seriously ill patients and their families, we must understand the concerns of parents with dependent children. These data underscore the importance of parenting-related worries in this population and the need for additional clinical and research programmes devoted to addressing these issues.
ROUTINE HIV TESTING IN AN INNER CITY EMERGENCY DEPARTMENT
Authors: Hunter LJ , Lojo Rial C , Larbalestier N , Paparello J
Published: November 2016

Objectives & Background

The National Institute of Clinical Excellence (NICE) and the Royal College of Emergency Medicine recommend that adults should be tested for HIV in endemic areas with a prevalence >0.2%. It is estimated that approximately 25% of those living with HIV are unaware of their diagnosis. Late diagnosis is associated with a ten-fold increased risk of death in the following year,1and increased risk of onwards HIV transmission. In July 2015 our Emergency Department commenced a pilot project to assess the feasibility of routine HIV testing within a busy inner city ED.

Methods

Patients over the age of 16 had an HIV test performed if they required venepuncture during their emergency department attendance. Tests were ordered using a pre-configured blood order set including a pre-selected HIV test. Patients were informed of the intention to test all attendances and were able to opt out if desired. Positive or equivocal results were followed up by our HIV team.

Results

Over 36 weeks, 64% of ED attendances (19,569/30,461) were tested for HIV. Our prevalence was 0.9% (n=172) and of those 0.3% were not aware of their positive HIV status (n=68). Thirteen patients were not currently engaged in services, although aware of their diagnosis. Median age was 36(18–61). Patients who tested positive were predominantly male (84%) and Caucasian (59%) (37% BME, 4% Asian).

50% of patients who tested positive self- identified as heterosexual, and 50% as MSM(men who have sex with men). A significant number (54%) of newly diagnosed patients had previously attended our emergency department prior to routine HIV testing. 23% of new diagnoses required an acute admission.

Conclusion

The Emergency Department provides a suitable environment for opportunistic HIV testing in areas of high prevalence. We have maintained testing rates of >65% of our ED attendances, achieved early diagnosis and treatment engagement in patients who were unaware of their HIV status. In addition, we have identified a number of patients who had been lost to follow-up and have now re-engaged in care. Use of pre-configured blood order sets, regular staff education and feedback on results improves testing rates.
MANAGEMENT OF HEAD INJURY IN THE HOSPITAL SETTING
Authors: Carnachan A , Savage R , Waters E , Elwen F
Published: November 2016

Objectives & Background

700,000 people visit Accident and Emergency (A&E) with head injuries annually. NICE have clear guidance as to how these patients are managed in hospital, as outlined below:

▸

A standard head injury proforma must be used in all clinical departments.

▸

Indication for a CT head in 1 hour, or 8 hours.

▸

Observations must be performed every 30 minutes for 2 hours, every hour for 4 hours, then 2 hourly.

▸

On discharge, verbal and printed advice must be given.

Guy's and St Thomas' Foundation Trust (GSTT) has developed a specific head injury proforma, which aims to implement these guidelines. Advice on the management of complex head injury cases is sought from neurosurgery at King's College Hospital.

Our study aims to determine how well head injuries are managed at GSTT in accordance with NICE guidelines, to identify and implement service improvements where necessary.

Methods

A search was performed on Symphony (A&E tracking system) for all codes to find adult (>18 years) head injury cases during the month of December 2015. Cases were investigated using paper notes, Symphony, e-noting, and EPR, and data was analysed using excel.

Results

251 head injury cases were seen in A&E in December 2015. The GSTT A&E head injury proforma was completed in only 9 cases.

A CT head was performed in 47 cases, of which 5 revealed an abnormality. 32 patients had an indication for CT in 8 hours. 12 did not receive scan at all, the remaining 20 all received scans within 8 hours. There were 27 patients who required a CT in 1 hour; 15 of these were performed in 1 hour after being seen (average time 59 minutes). 3 were not performed.

27 patients were admitted: 19 under medical teams, 3 under surgical teams, 5 under specific teams for other injuries. 1 patient was transferred to King's College Hospital. 5 patients were discussed with King's College Hospital, and in 4 cases advice was followed correctly.

Only 13 out of 27 patients admitted had neurological observations recorded in e-noting.

Conclusion

Although a relatively small study, it has highlighted the need for further education and training of staff in regards to the head injury guidance that exists within the trust, specifically in regards to comprehensive documentation.

There will be a focus on promoting the use of the head injury proforma in A&E, and making it readily available on all wards. With collaborative working with IT on e-noting, the plan is to ensure observations can be recorded and accessed quickly and easily.
IMPACT OF POINT OF CARE CRP TESTING ON THE MANAGEMENT OF PATIENTS WITH SUSPECTED COMMUNITY ACQUIRED PNEUMONIA IN THE ED
Authors: Robinson D , Till J
Published: November 2016

Objectives & Background

The World Health Organisation has identified antimicrobial resistance as “an increasingly serious threat to global public health that requires action across all government sectors and society”, and state that “health workers should only prescribe antibiotics when they are truly needed”.

The Emergency Department (ED) at Bradford Royal Infirmary is a busy urban ED, with significant numbers of patients attending with lower respiratory tract infections, particularly in the winter months. NICE CG191 (Pneumonia in Adults, December 2014) recommends the use of point of care (POC) CRP testing to guide antibiotic therapy inprimary care. This study aims to evaluate the impact of POC CRP testing inED patientswith low risk Community Acquired Pneumonia (CAP).

Methods

A before and after study was performed. We included adults (aged 16 years and above) presenting to the ED with suspected Lower Respiratory Tract Infection (LRTI) AND CURB-65 score 0–1. During the pre-intervention phase (November 2015–January 2016) patients were managed using the pre-existing ED CAP guideline. During the intervention phase (February–March 2016) patients meeting the inclusion criteria underwent POC CRP testing, and the results of this were used to guide antibiotic prescribing. Retrospective analysis of the ED documentation and hospital results systems was performed to determine antibiotic prescribing rates, return to the ED within 30 days, and subsequent new radiographic pneumonia within 30 days of ED presentation.

Results

143 patients were included (50 pre-intervention, 93 post-intervention). Baseline characteristics were similar in both study periods. Antibiotic prescribing rates were significantly lower in the POC CRP group (20% versus 70%, p<0.0001 Fisher's exact test). There was no significant difference in the proportion of patients returning to the ED within 30 days requiring further treatment for LRTI (2.2% POC CRP group versus 6% pre-intervention, p=0.34). No patients in either group developed new radiological pneumonia within 30 days of ED presentation.

Conclusion

The introduction of POC CRP testing in ED patients with suspected CAP led to a significant reduction in antibiotic prescribing rates. This is consistent with evidence from primary care and NICE guidance, and we advocate the wider use of POC CRP testing in this group of patients in the ED.
A MULTI-MODAL APPROACH TO QUALITY IMPROVEMENT: REDUCING 'DOOR-TO-CT' TIME IN POTENITALLY THOMBOLYSABLE STROKE PATIENTS
Authors: Waterson F , Braithwaite I , Tuck I , Alcock R
Published: November 2016

Objectives & Background

With 1.9 million neurons lost every minute a stroke is untreated1, rapid assessment and management is a time critical medical emergency, and is reliant on robust Emergency Department (ED) systems. Rapid access to CT imaging is an immediate priority to allow exclusion of patients with haemorrhagic stroke, an absolute contraindication to thrombolysis. Our QI project aimed to reduce the time from arrival in ED to CT scan for patients presenting with potentially thrombolysable stroke.

Methods

Using a combination of live and simulated stroke scenarios, we process-mapped the care of potentially thrombolysable patients through the ED at Forth Valley Royal Hospital. We identified ‘unnecessary’ delays from non-value adding activity and following consultation with the Scottish Ambulance Service, Radiology & Neurology, created a new pre-alert procedure and streamlined protocol for this patient group which facilitated rapid assessment, stabilization and early access to CT imaging.

We used a multi-modal approach to deliver change which included weekly clinical governance meetings, teaching for medical & nursing staff, in-situ simulation to educate and stress the system, regular safety brief announcements and the development of a ‘Stroke Awareness Week' at our hospital.

Results

Door to CT time was reduced by 40%, from 30 minutes (median 23) to 18 minutes (median 13), comparing 4 month sample periods before and after changes. During our QI project, Door-to-Needle (DTN) time has reduced from a mean of 81 minutes (in 2015) to a mean of 64 minutes (2016YTD).

Conclusion

Early thrombolysis has been shown to improve outcomes in patients with ischaemic stroke.2 Reducing ‘Door-to-CT' scan time in the ED is an important step in enabling a reduction in the overall DTN time. This can be achieved by stream-lining key processes in the patient journey through the ED. A multi-modal approach ensured this change was introduced safely and effectively whilst re-enforcing a core change to standard working practice. Further work on process mapping and the delivery of thrombolysis is the next obvious step in further reduction in DTN time.

Figure 1

Quality Improvement Run Chart 'Door-to-CT' time with change processes highlighted
THE DAY MY HEART SKIPPED A BEAT. SAFE, CONSISTENT AND EFFECTIVE MANAGEMENT OF ATRIAL FIBRILLATION IN THE EMERGENCY DEPARTMENT
Authors: Summerhayes R , Cartwright N , Quartermain A
Published: November 2016

Objectives & Background

Atrial Fibrillation (AF) is a common presentation to the Emergency Department. However there is marked inconsistency in how patients are managed.

Professor Mark Baker, NICE's Director of Clinical Practice:“AF increases the risk of strokes by up to five times. It's estimated that the condition causes around 12,500 strokes each year…. Unfortunately only half of those who should be getting these drugs (anticoagulants), are. This needs to change.”

An audit of practice in December 2015 UHS ED revealed that only 10% had any documented stroke risk stratification.

The aims of our Quality Improvement Project were:

▸

To provide a standardised, evidence based approach to the management of newly diagnosed AF in UHS ED.

▸

Reduce the admission rate of patients attending ED with AF.

▸

Improve patient safety by ensuring patients are appropriately risk stratified and anticoagulated.

Methods

▸ Review of literature and current guidelines. NICE 2014, ESC 2012, AHA 2014. We created a pragmatic and evidence based ‘Management of AF Pathway' agreed by ED/Cardiology/Pharmacy and Governance leads. The pathway went through several PDSA cycles.

▸ We created process maps looking at the journey of patients with AF to identify delays in investigation, diagnosis and treatment. If patients with new AF are treated in a timely manner successful rate/rhytm control can be achieved in a greater proportion within 4 hrs and therefore discharged with follow up.

▸ Clinician education and clear guidance with regard to risk stratification and anticoagulation.

Results

The results of this QuIP are:

▸ A locally agreed, evidence based approach to the management of newly diagnosed AF.

Outcome 2 and 3 are represented by Run Charts demonstrating Discharge Rate over time and Risk Stratification/anticoagulation over time.

▸ Admission rates fluctuated around 60%. There was no significant change after implementation of changes.

▸ There was a huge change in numbers of patients risk stratified/anticoagulated. The initial rate was 10% increasing to 85% in the most recent data collected.

Conclusion

The management of AF is complex. However it is possible to create and implement a locally agreed, evidence based guideline which is well received by both ED physicians and Cardiology. We have demonstrated a marked improvement in stroke risk stratification/anticoagulation and therefore impacted on patient safety.

Figure 1
THE PARAMEDIC ULTRASOUND IN CARDIAC ARREST STUDY
Authors: Reed MJ , Gibson L , Black P , Dewar A , Clegg G , Short S
Published: November 2016

Objectives & Background

The Edinburgh 3RU paramedics have some advanced training in cardiac arrest (CA) management

The PUCA study aimed to see whether pre-hospital paramedics can

▸

be trained to perform and [2] interpret pre-hospital ELS

▸

retain ELS performance and interpretation skills

▸

perform satisfactory pre-hospital ELS

▸

perform pre-hospital ELS without impacting CA care

Methods

Phase 1 – Testing/purchasing a suitable ultrasound machine

Phase 2 – Formal classroom based training: one-day training course with practical and moulage sessions.

Phase 3 – Field based training.

Phase 4 – Prospective observational study of pre-hospital paramedic ELS using saved ultrasound clips and wearable camera videos.

Results

During classroom based training, all paramedics could obtain parasternal (PS) and subxiphoid (SX) images.

▸ 88% of attempts in both views were successful in the pulse check window.

▸ Theoretical knowledge improved (mean pre vs post course score 54% vs 89%; p<0.001) and at 10 weeks was non-significantly reduced (82%; p=0.13) but less so than practical performance (75% SX success, 25% PS success).

▸ By Sep 2015, 8 of 11 paramedics who attended initial training, had passed a triggered competency assessment and were practicing pre-hospital ELS independently.

▸ Between 23rd June 2014 and 31st Jan 2016, seven 3RU paramedics attended 45 patients suffering out-of-hospital CA where resuscitation was attempted and the Venue 40 ultrasound machine was available and used.

▸ 80% of first paramedic ELS attempts produced an adequate view which was excellent/good/satisfactory in 68%.

▸ 44% of views were obtained within the pulse check window with a median time off the chest of 17 seconds (IQR 13–20).

▸ A decision to perform ELS was communicated in 67% and the pulse check counted aloud in 60%.

▸ A manual pulse check was seen to be performed in a quarter of patients and the monitor rhythm checked in 38%.

▸ All decision changing scans involved a decision to stop resuscitation.

Conclusion

Paramedics can perform focussed ELS in the classroom, integrate attempts into simulated CA scenarios and retain some of this knowledge.

▸ They obtain good ELS views in the pre-hospital environment but with longer hands off the chest times.

▸ The quality of life support may be reduced with less obvious pulse and monitor checking.

▸ Paramedic pre-hospital ELS is more likely to be performed in patients where discontinuation of resuscitation is being considered.

▸ Further training should focus on improving ELS situational awareness.
FCP AND THE ED: SAVING LIVES THROUGH ORGANISING CARE.
Authors: McGowan H , Gopeesingh K , Gilligan P , O'Kelly P
Published: November 2016

Objectives & Background

Hospital overcrowding is a problem that manifests in the Emergency Department (ED) and causes poorer patient outcomes. In an effort to combat overcrowding full capacity protocols have been put in place to move patients from the ED to temporary extra beds placed in the inpatient wards. This improves patient flow in the ED allowing for better provision of care to patients. This study aims to gauge patient opinion on being placed in extra beds rather than staying in the emergency department.

Methods

Through a review of current literature the current full capacity protocol in Beaumont Hospital, Dublin was updated to reflect best practice and national guidelines. A structured questionnaire was employed to assess patient attitudes towards boarding in the ED and on the extra beds and to determine the preference patients had on where they would prefer to be boarded as an additional patient.

Results

75 patients took part in the study. 86.67% indicated a preference for being an additional patient on the ward, 10.67% had no preference and the remaining 2.67% preferred being boarded in the ED. This data agreed with similar studies from other centres internationally.

Conclusion

Moving patients from the ED into extra beds on the wards frees up space in the ED and enables staff to more effectively treat patients. The vast majority of patients are understanding of the issues facing modern healthcare providers and welcome the opportunity to be moved to quieter, more comfortable areas where they can have better access to the quality healthcare that hospitals exist to provide them with.

Figure 1

Figure 2
WHAT SHOULD BE DONE TO REDUCE EMERGENCY DEPARTMENT CROWDING? – A DELPHI STUDY
Authors: MacDonald-Nethercott E , Richter S , Boyle A , Higginson I
Published: November 2016

Objectives & Background

Emergency department crowding is a serious public health problem throughout the developed world. In 2015 the UK Royal College of Emergency Medicine was charged by its executive with producing a toolkit to reduce crowding. This study was commissioned to inform said toolkit. The goal of the study was to develop a list of interventions to deal with crowding and exit block, based on consensus of a group of senior emergency physicians.

Methods

The Delphi technique was used to undertake a formal blinded consensus study. 33 experts were invited. These were committee members of the Royal College of Emergency Medicine who worked as emergency physicians in a diverse range of UK hospitals. Responses were collected using the web based survey tool SurveyMonkey over eight weeks in spring 2015. In round 1, experts suggested interventions to reduce crowding. In round 2, experts reviewed all proposals. Any proposal that was endorsed by at least 80% of experts (level chosen a priori) was included in the final recommendations. The authors then decided which professional role would be most able to deliver each intervention.

Results

Of 33 experts invited, 23 agreed to participate in round 1 and 18 in round 2. In round 1, respondents submitted 310 proposals which was reduced to 188 proposals when duplicates and irrelevant comments were removed. In round 1, 117 proposals reached the threshold of 80% agreement. These included 112 interventions recommended to reduce crowding (20 input, 40 throughput, 37 output and 15 multi-dimensional measures) as well as 5 interventions that should be avoided.

Conclusion

We have developed a list of 117 expert-endorsed recommendations to deal with emergency department crowding. We not only identified which interventions to implement but also which to avoid. For each intervention we decided who should deliver it. Our findings provide useful advice to clinicians, commissioners, managers and policy makers.
PATIENTS ADMITTED FROM THE EMERGENCY DEPARTMENT INTO AN ACUTE MEDICINE BED FOR LESS THAN TWENTY FOUR HOURS–ARE THESE ADMISSIONS JUSTIFIED?
Authors: Clancy M , Gray H
Published: November 2016

Objectives & Background

The increase in emergency admissions over the past 15 years has come almost entirely from the EDs,for patients who spend two days or less in hospital. It has been suggested that these cases are of low severity and admitted because of a lack of alternative services, defensive medicine and the four hour target. We wished to develop means of classification as to whether the admission was jusitified or not using both explicit critiera and implicit expert approaches.

Methods

Explicit approach: we wished to use the activities recorded in the patients medical and nursing notes covering their time in the AMU relating to observations (type, frequency and values), investigations (type and values), treatments (type and frequency), specialist review (specialty and grade) and post discharge care to generate a list of ‘candidate’ criteria. Candidate criteria were developed after review of 100 sets of notes.Three consultants in Acute Medicine were asked for each criterion –“would its presence justify admission?” and a majority verdict taken. The list of criteria was then that applied to 300 consecutie patients admitted to the Acute medical Unit. Unjustified cases would be those with the absence of any justifiable critieria.

Implicit approach: three different consultants in Acute Medicine were given copies of 120 randomly chosen patients anonymised notes and independently asked to judge if the patients admission was jusitified or not and a majority decision was taken.

Results

Between January and August 2014, 24% of patients attending the ED ( 13766), were admitted to the hospital. 5802 of these were admitted to AMU of which 1063(18%) stayed less than 24 hours ( approximately 150 /month).

We studied 300 consecutive patients. Table 1 (screen shot) shows the criteria agreed by the expert panel,whose presence would justify admission together with their frequencies. Patients could meet more than one criteria. 275 met one or more of the AMU criteria (92%).Of the 120 cases reviewed by experts, 84 (70%) were considered justified and 36 unjustified.

Conclusion

Using the explicit criteria 92% of cases were justified, and 70% by use of the expert panel note review. This does not suggest an excessive admission rate for the population that we have described, who can be both difficult to assess and to rapidly exclude serious pathology.
TRENDS IN VIOLENCE IN ENGLAND AND WALES 2010–2014
Authors: Sivarajasingam V , Page N , Shepherd J , Moore S
Published: November 2016

Objectives & Background

The National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied.

Methods

Data on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

Results

In total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/ 1000 population (95% CI 3.9 to 4.9); males 6.5/1000 (95% CI 5.6 to 7.2) and females 2.4/1000 (95% CI 2.1 to 2.6). On average, overall attendances decreased by 13.8% per year over the 5 years (95% CI −14.8 to −12.1). Attendances decreased significantly for both genders and all age groups (0–10, 11–17, 18–30, 31–50, 51+ years); declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July.

Conclusion

From an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May–July.

Figure 1

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Figure 5
MORTALITY OF EMERGENCY PATIENTS IN A TERTIARY REFERRAL HOSPITAL IN SIERRA LEONE–BASELINE RATE AND CORRELATION WITH ADMISSION TRIAGE CATEGORY
Authors: Tolppa T , Lowsby R , Harrison H , Evans G , Kamara C
Published: November 2016

Objectives & Background

Despite the increasing burden of trauma and acute illness in low and middle-income countries, emergency care in these countries remains immature and there is a lack of robust data regarding mortality. Emergency care at the main governmental referral hospital in Freetown, Sierra Leone has been redeveloped in the wake of the Ebola epidemic. Initiatives include twenty-four hour triage, a resuscitation bay and an acute medical unit. Mortality within the unit is noted down for emergency admissions, but to date, the information has not been collated or reviewed. This study aimed to determine the baseline mortality rate within the acute medical unit and to assess correlation with triage category on arrival.

Methods

The aims of this study were achieved by carrying out a retrospective review of emergency admissions at a tertiary referral hospital with 300 beds. The number of new admissions, deaths within the acute medical unit and the admission triage category of deceased patients were obtained from ledgers for a six-month period between January and June 2016. The triage categories are based on the South African Triage Scale (SATS) and include, in an order of increasing severity, green, yellow, orange and red. Patients that arrived dead to the department were excluded from the study. Pearson's correlation was used to test for an association between triage category and mortality.

Results

A total of 1657 acute medical unit admissions were recorded during the study period. The overall mortality was 10.5% (n=174). There was a strong positive correlation between triage category on arrival and mortality, which was statistically significant (r=.986, n=145, p=0.014). Only one deceased patient was assigned to the green category, which on review was found to belong to the orange category. Triage category was not recorded for 29 deceased patients (16.7%).

Conclusion

The study represents the first effort in the acute medical unit to review emergency patient mortality and serves as a baseline for future data collection and comparison. This basic method of mortality data collection could be adopted in other units and local healthcare facilities in order to produce comparable data, which does not currently exist. The strong correlation between the assigned triage category and mortality highlights the value of triage in identifying the patients most at risk of dying.
USING A FINGERPRINT-ACCESS MEDICATION CABINET TO IMPROVE EFFICIENCY IN AN EMERGENCY DEPARTMENT.
Authors: Ragoo M
Published: November 2016

Objectives & Background

Compliance with UK pharmacy standards requires medications to be stored in a locked cupboard. This creates inefficiency in a busy emergency department (ED) as there are delays locating the keys, then finding the medications in the cupboard. We report the efficiency gains of an Omnicell cabinet which is accessed by staff fingerprint and has a system of guiding lights to identify the requested medication within the cabinet. This is a prospective observational study comparing the time from prescription to administration of medications before and after the installation of an Omnicell.

Methods

The study setting was a tertiary academic centre in England with 130,000 attendances per annum. Prior to the installation of the Omnicell, we measured the time taken in minutes (min) for the nurse to locate the keys to the drug cupboard. We also measured the dispensing time. This was measured as the time from when the nurse reads the prescription of an oral medication to when the tablets were physically obtained by the nurse. A research nurse not involved in the care of the patient measured the dispensing time for a convenience sample of 100 patients over a four week period. A second convenience sample was collected 6 months after the installation of the cabinet. Participants were unaware of the study outcomes.

Results

The mean time to locate the keys prior to the implementation of the Omnicell was 2.4 min (sd 2.7 min, n=110). The mean time taken to dispense medication prior to implementation was 7.5 min (sd 13 min, n=110) and after implementation was 1.1 min (sd 0.7 min, n=107). The mean time difference was 6.4 min (idependent t-test, 95% CI 3.9 to 8.9 min).

Conclusion

This is the first study in a UK civilian ED to quantify the efficiency gains of the implementation of an Omnicell cabinet. We demonstrated that there was a time saving by removing the need to locate keys for the medication but this was only an average of 2.4 min. We underestimated the time saving that was made by having a system of guiding lights which directed the user to the correct medication within the cabinet. This contributed to the overall time saving of 6.4 min for every medication prescribed. This represents a significant improvement in efficiency in a large busy ED with more than three hundred attendences a day.
PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT – HOW WELL TRAINED ARE OUR STAFF?
Authors: Currer M , Trudeau T , Laura H
Published: November 2016

Objectives & Background

Over recent years,our middle grade cover has become more variable in terms of seniority and experience. In addition, we have undergone a rapid turnover of nursing staff, with more senior staff being replaced by highly motivated but less experienced nurses. Historically, there has been little formal teaching on procedural sedation, with most staff picking up skills “on the job”. However, with changing staffing profile coupled with recently published guidance, we felt a more structured approach was required.

Methods

Emergency Department (ED) medical and nursing staff of all grades were asked to complete an on-line survey in order to determine levels of confidence, and aspects of sedation where they felt knowledge could be improved.

Results

We received 38 responses, 17 from senior doctors (consultants, ST 4–6 and equivalent) 12 from junior doctors (all other grades) 9 from nursing staff. 31 of 38 (81%) felt that more teaching on sedation would be beneficial. All those answering “no” were senior doctors.

Responders were asked to rate their confidence in pre procedural assessment, use and selection of medications, airway management, patient monitoring and safe discharge of patients. There was unsurprisingly considerable variation between groups. However, use and selection of medications was notably lower in all groups.

In the free text options, topics commonly cited were pharmacology, identifying and managing complications and need for scenario/simulation sessions.

Conclusion

The results of this survey were utilised to inform development of a teaching programme for all staff in the department, consisting of written material, case based tutorials and subsequent in-situ simulation sessions.

Teaching packs are slightly different for nurses and medical staff but focus on patient selection; drug choice with notes on pharmacokinetics and pharmacodynamics, potential side effects and complications and important interactions; monitoring, and criteria for stopping close monitoring and for discharge.

Case based tutorials are aimed at all staff, with scope for varying discussion topics according to the learners needs.

The department already runs regular in – situ simulation sessions, and some standard sedation scenarios have been added to these sessions.

In future, we plan to develop an on-line module for staff to undertake with a self assessment component.

Table 1

Confidence Levels for aspects of procedural sedation

Senior DoctorJunior DoctorNurseOverallPre procedure assessment4.442.732.753.51Selection and use of medication4.192.002.883.20Airway management4.53.273.503.89Procedural monitoring4.693.093.884.00Safe discharge of patients4.632.453.883.77
ACCIDENT & EMERGENCY PERFORMANCE AND SENIOR DOCTOR INITIAL ASSESSMENT MODEL; NATIONAL DATA ANALYSIS FOR ENGLISH NHS HOSPITAL TRUSTS
Authors: Abdulwahid MA , Turner J , Mason S
Published: November 2016

Objectives & Background

A number of systematic reviews of triage related interventions showed that there is a growing interest senior doctors performing initial assessment on patients.

This study aimed to answer the following question: How do NHS trusts (NHSTs) with senior doctor assessment compare on key performance metrics such the percentage of patients waiting for more than four hours with their counterparts with no senior doctor initial assessment at triage?

Methods

This was a retrospective study of English emergency departments (EDs) performance (routine A&E quality indicators analysis) from July 2014–June 2015 at NHST level. Trusts were divided into two main groups according to their triage practice.

These were identified in a national survey of ED triage practices across England. The first model was a group of fifty NHSTs that operated senior doctor initial assessment of ambulance arrivals or walk-in patients. This was compared to fifty-seven NHSTs with EDs that did not operate senior doctor initial assessment including EDs that trialled this model in the past.

Relevant statistical tests were undertaken to examine the possibility of a statistical significant difference amongst the A&E quality indicators across NHST groups.

Results

Analysis of data showed that NHSTs with and the NHSTs without senior initial assessment in triage had similar performance with regard to all measured outcomes.

It should be noted that the performance of NHSTs with senior doctor triage slightly improved on all measured outcomes after adjusting for confounding factors such as attendance rate. However, this was not statistically significant.

Conclusion

Examining the output of the analysis and relative statistical tests, there is insufficient evidence to suggest that senior initial assessment in triage improve ED performance.

Hence, the study findings do not support the use of senior initial assessment in triage.

Figure 1
CONSULTUS INTERRUPTUS: UNSCHEDULED INTERACTIONS WITHIN THE EMERGENCY DEPARTMENT
Authors: Gill SS , Paw R , Doyle P , Shah A , Al-Shakhshir S , Abukhder M
Published: November 2016

Introduction

The job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.

Objectives

This study attempted to answer the following questions

1. In a day how many unscheduled interactions does the senior EM physician deal with?

2. How many of these are interactions are clinical interactions?

3. What is the average length of time spent dealing with these unscheduled interactions?

Methods

This prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was shadowed on shift by a medical student who recorded all non-patient interactions involving the consultant. The consultant had no input into data collection. The nature of the UI,, the time spent; and the outcome were recorded on a data collection form. This was then collated and analysed.

Results

A total of 23 shifts over 135 hours 34 minutes were observed.There was a mix of early (0800–1600), late (1600–2100) and weekend shifts.

▸ All 10 members of the consultant body were observed.

▸ Total Number of UI in study period: 2082

▸ Average Number of UI per hour: 17.95 UI/hour.

▸ UI rate (time per UI): 3 minutes 22 seconds

▸ Average time per UI: 87.5 seconds (Range 10 seconds–34 minutes).

▸ Clinical vs Non Clinical Interactions: 94% vs 6%.

Conclusion

In this single centre study of an urban UK emergency department, 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 seconds

Discussion

Modern EM relise on a senior EM physician, running an organised shift, to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load is not feasible and departments should consider the initiation of a ‘captain of the ship,’ or ‘Fat Controller’ role along with a second senior EM physician to provide individual consultant level care to the sickest individuals who require senior input.