bluuebunny/crossref_metadata_2025 huggingface dataset:
1428 What influences decisions and predicts transfer of older care-home residents to the emergency department? A synthesis of qualitative reviews and systematic review
Authors: Marincowitz Carl , Preston Louise , Cantrell Anna , Tonkins Mike , Sabir Lisa , Mason Suzanne
Published: December 2022

Aims, Objectives and Background

The proportion of adults aged over 65 is rapidly increasing in developed countries. Care home residents have disproportionate rates of transfer to the ED. An estimated 40% of emergency admissions for care home residents may be for avoidable conditions and up to 8-fold variation in hospitalisations has been identified between care homes

We aimed to synthesise the qualitative research collated in existing reviews relating to the experience of residents, family members and professionals in decisions to transfer care home residents to the ED and identify known factors which predict ED transfer from care homes.

Method and Design

Two systematic reviews were conducted simultaneously. The first identified and synthesised the qualitative evidence presented in existing systematic reviews regarding decisions to transfer residents to the ED. The second identified quantitative factors found to affect likelihood of transfer of residents. Five electronic databases were searched, including: MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and Scopus.

Results and Conclusion

In the qualitative component, six previous reviews met the inclusion criteria. Three syntheses were formed : (i) Transfer decisions involve negotiation with unequal power dynamics between residents, family members, care home staff and clinical practitioners (ii) Some transfers occur with the expectation that treatment in hospital will improve outcomes (iii) Some transfers occur due to factors external to the resident with no expectation that hospitalisation will be beneficial.

Twenty-six primary studies met the inclusion criteria for the quantitative component. Seven common domains of factors associated with ED transfer were identified: demographics, co-morbidities, medication use, frailty, permanent indwelling devices, advanced directives and care home organisation. Within these domains, male sex, age, presence of specific comorbidities, polypharmacy and quality rating were associated with ED transfer across studies.

This provides context for policy makers and researchers developing interventions to reduce hospitalisations or use adjusted rates of hospitalisations as a care home quality indicator.
1491 Determinants of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia
Authors: Price James , Lachowycz Kate , Major Rob , Moncur Lyle , McLachlan Sarah , Keeliher Chris , Steel Alistair , Barnard Ed
Published: December 2022

Aims, Objectives and Background

Prehospital emergency anaesthesia (PHEA) is a safe and necessary procedure for the most seriously injured trauma patients. The avoidance of secondary insults such as hypoxia and hypotension are key to reduce mortality. Despite this, a proportion of patients experience post-intubation hypotension (PIH), for which the determinants remain unclear. This multi-centre study aims to compare the differential determinants of PIH in trauma patients undergoing PHEA.

Method and Design

In this retrospective observational study, across three regional Helicopter Emergency Medical Services (HEMS), data were obtained from the electronic medical records for a consecutive sample of adult trauma patients who underwent PHEA, 2015–2020 inclusive.

Hypotension was defined as new systolic blood pressure (SBP) <90mmHg or >10% drop if SBP<90mmHg pre-PHEA, within 10 minutes of PHEA. A purposeful selection logistic regression model was used. Each variable was first tested in turn to explore the unadjusted association with the outcome. Significant variables were then included in the multivariable analysis. Variables were successively eliminated until only statistically significant variables remained. The ARU Research Ethics Panel granted ethical approval (AH-SREP-20–047).

Results and Conclusion

During the study period, 6184 patients were identified. After predefined exclusions, 998 patients were included in the final analysis. 218 (21.8%) patients recorded one or more episodes of PIH, with a peak prevalence at 8 minutes. The variables significantly associated with PIH were: age >55 years, pre-PHEA tachycardia (>100/minute), fluid administration prior to HEMS arrival, and fentanyl omission at induction, table 1.

The pseudo-R2 for the final model suggests there is significant variation in the outcome not explained by the captured variables alone. Clinician gestalt appears to successfully identify patients most at-risk of PIH, demonstrated by the omission of fentanyl for this group.

Abstract 1491 Table 1

Multivariate analysis of variables associated with post-induction hypotension within 10 minutes of prehospital emergency anaesthesia

In addition to drug-dose modification, pre-PHEA volume administration, cautious haemodynamic observation, and early vasopressor intervention may be warranted to reduce avoidable harm in trauma patients undergoing PHEA.
1423 The positives, the challenges and the impact: an exploration of early careers nurses experiences in the Emergency Department
Authors: Skene Imogen , Power Helen , Murray Esther
Published: December 2022

Aims, Objectives and Background

The intense working environment of the Emergency Department (ED) is exciting and rewarding; but is renowned for high staff turnover and burnout. The wellbeing and retention of the existing workforce is imperative. The purpose of this study was to explore the experiences of early careers nurses in the ED; identify aspects of ED they enjoyed, the challenges and explore potential coping mechanisms used to mitigate negative situations.

Method and Design

A qualitative design was used. Eleven semi-structured interviews were conducted with adult and paediatric emergency nurses who had worked in the ED for less than three years. Data were transcribed, coded and analysed using thematic analysis. The setting for this study was an emergency department in a major trauma centre. Data was collected between January-August 2020 following ethical approval.

Results and Conclusion

Four key themes emerged; (1) Drawn to ED Nursing’ ; (2) ‘Teamwork’; (3)‘Time to care’ and (4) ‘Psychological impact’’. Opportunities for learning and development and being able to provide good levels of patient care were identified important to participants. Challenging aspects of the job included high workloads, exposure to traumatic incidents, violence and aggression. The psychological impact included feelings of burnout, exhaustion, flashbacks, personal growth and perspective. Teamwork, a strong support network and opportunities for formal and informal debrief were identified as helping to mitigate challenging aspects of the job

By identifying the factors that maintain wellbeing and sustain the workforce, we can promote and support them. The benefits to a stable and well supported workforce in ED are many; improved and sustainable patient care, reduced staff turnover and alleviating pressures on the existing workforce. Research is now drawing on how we can provide psychological support to those who have been faced with caring for patients in a way that challenges their own moral framework.
1723 Diagnostic accuracy of a novel transcriptomic classifier for bacterial and viral infections – an individual patient data meta-analysis
Authors: Uhle Florian ,   Pilot Study Investigator group, Evangelos Giamarellos-Bourboulis, Bauer Wolfgang , Sun Lisa , Chen Uan-I , Sweeney Timothy E , Liesenfeld Oliver
Published: December 2022

Aims, Objectives and Background

Arising from demographic differences between healthcare systems, patients in the emergency department (ED) present with a broad range of diagnoses and clinical severities. Independent validation of a novel diagnostic tool is critical to ensure reliable and reproducible clinical performance. So far, three independent cohort studies have validated the performance of the machine-learning classifier IMX-Bacterial/Viral/Non-infected (IMX-BVN) to diagnose bacterial and viral infections; those have been combined to facilitate an individual patient data meta-analysis of performance.

Method and Design

ED patients (n=1,277) with suspected infection from three international, observational studies (USA/Germany/Greece) were included. Of those, 661 had a unanimous (‘consensus’) ground truth of infection status established by panel adjudication. Quantitative expression of 29-signature mRNAs was measured on a NanoString nCounter® SPRINT system. The classifier BVN version 3 (IMX-BVN-3) was applied to generate scores, which fall into four discrete interpretation bands (very unlikely, unlikely, possible, very likely). Sensitivity, specificity, and corresponding nominal likelihood ratios were calculated with 95% confidence intervals for each interpretation band.

Results and Conclusion

360 patients (54.4%) were consensus adjudicated to have a bacterial infection (range: 37.9–81.2%) and 153 (23.1%) to have a viral infection (range: 15.3–44.1%). Pooled likelihood ratios of the interpretation bands for bacterial infections were (from ‘very unlikely bacterial’ to ‘very likely bacterial’) 0.082 (0.039–0.176)/0.333 (0.264–0.419)/2.244 (1.598–3.152)/9.459 (5.808–15.404), associated with a rule-in specificity of 0.947 (0.915–0.967) and a rule-out sensitivity of 0.981 (0.960–0.991) in the outer interpretation bands. Pooled likelihood ratios of the interpretation bands for viral infections were (from ‘very unlikely viral’ to ‘very likely viral’) 0.182 (0.102–0.324)/0.292 (0.181–0.471)/0.956 (0.593–1.540)/6.021 (4.636–7.821), associated with a rule-in specificity of 0.884 (0.853–0.909) and rule-out sensitivity of 0.928 (0.876–0.959).

The IMX-BVN-3 classifier exhibits strong performance in a combined cohort of patients from different geographies and settings to rule-in and rule-out patients presenting to EDs with suspected bacterial and viral infections.
1716 Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis
Authors: McLatchie Rachel , Wilson Sarah , Reed Matthew , Ticehurst Francoise , Easterford Kathryn , Alawiye Salma , Cowan Alicia , Gupta Aakash
Published: December 2022

Aims, Objectives and Background

Acute aortic syndrome (AAS) is a rare, life-threatening emergency affecting approximately 4000 people per year in the UK, has an ED misdiagnosis rate as high as 38% and around one quarter of cases are not diagnosed until 24 hours after presenting to the ED.

It presents in many atypical ways, posing a significant diagnostic conundrum for the emergency department (ED) clinician and risk of litigation. We sought to understand the reasons why AAS was missed in ED by conducting a case series review of patients with misidentified AAS presenting to three UK EDs over a 10-year period.

Method and Design

We identified missed diagnoses of AAS using searches of ED morbidity and mortality records, post-mortem reports, complaints, Electronic Patient Records (EPRs) and Radiology records from three UK EDs.

Results and Conclusion

Between 1.1.2011–31.12.2020, 43 cases were identified across three EDs (1.4 cases/yr/dept).

The most common diagnosis was Type A aortic dissection (22; 51%).

The most common incorrect presumed diagnoses made were acute coronary syndrome (ACS, 12; 28%), pulmonary embolism (PE, 5; 12%) and ‘non-specific chest pain’ (5; 12%).

In 31 of the 43 cases (72%) there was no evidence from the notes of consideration of AAS in the differential diagnosis. In 10 of the 43 cases (23%), AAS was clearly considered, but the clinician appears to have been falsely reassured by clinical findings, normal chest x-ray, or atypical or resolved symptoms.

Only 63% (27/43) presented with chest pain and 16% (7/43) had no pain. 65% (28/43) documented sudden onset of symptoms.

This case series reinforces the RCEM/RCR recommendation that ‘All clinicians working in the emergency department should be made aware of the difficulties in excluding the diagnosis of thoracic aortic dissection.’ Further research is required to improve ED diagnostic pathways for this group of patients.
1456 Fatal propranolol overdoses reported to the UK National Poisons Information Service (NPIS) over 5 years 01/01/2017–31/12/2021
Authors: Williams Hayley , Jagpal Pardeep , Sandilands Euan , Gray Laurence , Thanacoody Ruben , Bradberry Sally
Published: December 2022

Aims, Objectives and Background

Propranolol is widely prescribed and between 2007 and 2017 dispensing in the UK increased by some 41%. In the same period, deaths in England and Wales following propranolol overdose increased by 205%.

Method and Design

We retrospectively reviewed cases of fatal propranolol poisoning reported to the UK NPIS, between 01/01/2017 and 31/12/2021 to understand the demographics of these exposures, the doses involved and treatments administered.

Results and Conclusion

There were 46 fatalities (aged 14–70 years) with 57% (n=26) of them being less than 40 years of age, and the majority of these being female (77%; n=20). Thirteen cases involved propranolol only and in the 33 cases of mixed overdose the mean number of co-ingestants was two, with a maximum of 13. An antidepressant was co-ingested in 21 cases. The reported dose of propranolol ingested was documented in 23/46 cases, median 3,200 mg (IQR 1,920–4,480 mg) and in three patients exceeded 7,000 mg. Cardiac arrest prior to contact with the NPIS was recorded in 41/46 cases. Fourteen (34%) occurred in hospital and twenty-three out-of-hospital (56%). Patients received: sodium bicarbonate (n=30, 65%), glucagon bolus and/or infusion (n=38, 83%), high dose insulin/dextrose (n=36, 78%), inotropes or vasopressors (n=36, 78%), intralipid (n=25, 54%) and ECMO was commenced in two cases. The dose of insulin administered was known in 15 cases (median dose 4 unit/kg/hour). Doses more than or equal to 8 unit/kg/hour were given in 7 cases (maximum 10 unit/kg/hour in three cases).

Young adults particularly females accounted for the majority of fatalities. In almost half of all cases an antidepressant was co-ingested. Clinicians should be aware of the potential for rapid deterioration and severe clinical outcomes following propranolol overdose. Rapid access to expert clinical advice is available through the National Poisons Information Service and is strongly recommended in order to optimise use of available treatments.
1655 The ‘CCHILDS’ screen: a practical guide to a consultation with refugee and asylum seeking children within the Paediatric Emergency Department (PED)
Authors: Chawla Jaya , Houbby Nour , Davies Sarah , Stewart Charles
Published: December 2022

Aims, Objectives and Background

The number of refugees worldwide has increased, especially in recent times, due to wars, political instability and economic insecurity with Iran, Eritrea, Albania, Iraq and Syria being the top five countries for asylum applications. Consequently, there are increasing numbers of refugee and asylum-seeking children entering the United Kingdom who face significant barriers to accessing healthcare services. These children often face health risks and therefore have complex health needs. Hence, it is vital for healthcare professionals in the emergency department to adopt a holistic approach to their care as this can have widespread positive implications beyond their clinical presentation and may shape their transition into a new country. This opinion article was undertaken with the aim of highlighting and summarising current best practice recommendations for addressing the needs of this complex patient group.

Method and Design

A step-by-step screening tool (figure 1), CCHILDS (Communication, Communicable diseases, Health – physical and mental, Immunisation, Look after (safeguarding), Deficiencies, Sexual health) was formulated. This was created following a review of the literature, consultation with paediatric emergency clinicians and the use of current protocols in related disciplines (e.g. HEADDSS assessment tool). This tool can be used in the emergency setting by healthcare professionals in the assessment of refugee and asylum-seeking children and can serve as an aide memoire to cover the key aspects of a consultation.

Abstract 1655 Figure 1

Results and Conclusion

This opinion article summarises three main aspects in the assessment of a refugee or asylum-seeking child in the paediatric emergency department. Firstly, the key considerations regarding the child’s background prior to entering the UK and the barriers they may encounter to accessing healthcare. Secondly, the healthcare assessment upon arrival to the emergency department and a framework that could be used for clinical assessment. Finally, the consideration of their long-term healthcare needs and the importance of empowering these young individuals to lead a healthy lifestyle.
1657 Trauma imaging appropriateness in paediatric patients conveyed to a trauma unit compared to a major trauma centre – a retrospective observational study
Authors: Hibberd Owen , Price James , Laurent Amy , Agrawal Shruti , Barnard Edward
Published: December 2022

Aims, Objectives and Background

Appropriate and timely imaging improves trauma outcomes. In adults, the default is whole-body computed tomography (CT). However, in children more selective imaging should be used. In those requiring CT, the national standard is imaging ≤30mins of arrival. The aims of this study were to compare appropriateness of CT and time to initial CT in paediatric trauma patients conveyed directly to a major trauma centre (MTC) with those initially treated in a trauma unit (TU) and then transferred to an MTC.

Method and Design

A retrospective observational study in the East of England MTC (2015–2020). All paediatric trauma patients meeting Trauma Audit Research Network (TARN) criteria who arrived at the MTC ≤24hr of injury and underwent CT imaging within 12 hours of arrival were included.

Data were obtained from the MTC trauma office and clinical records were independently reviewed by two authors. The Royal College of Radiologists guideline for paediatric trauma was used to assess the appropriateness of the CT imaging strategy.Combined data were stored in a Microsoft Excel sheet and analysed in Prism 9 for macOS (GraphPad). Data are reported as number (percentage), and median [inter-quartile range]. Proportions were compared with a Fisher’s Exact test; differences between median values were compared with a Mann-Whitney U test.

Results and Conclusion

In the study period n=315 patients were identified. 229 (72.7%) underwent CT <12hrs and were included in the analysis: n=93 MTC, n=136 TU, table 1. CT imaging was judged as appropriate in n=77/93 (82.8%) MTC and n=104/136 (76.5%) TU scans, p=0.32. The median time to first CT was 35.0 [26.0–75.0] minutes MTC, and 76.0 [48.0–109.0] minutes TU, p<0.0001.

Abstract 1657 Table 1

CT appropriateness and timing associated with transfer status at a single MTC

Primary Attendance to MTCSecondary Transfer to MTCCT <12 hours of hospital arrival/n(%)93 (41%)136 (59%)Age in years/median [IQR]9.8 [5.4 – 14.1]9.3 [3.5 – 13.8]Male sex/n (%)58 (62%)96 (71%)Injury Severity Score/median/[IQR]18 [10 – 29]16 [15 – 25]Hospital arrival to first CT interval (minutes)/median [IQR]35 [26–75]75 [47–108]CT whole body (% of CT at TU/MTC)47 (51%)47 (35%)CT focussed (% of CT at TU/MTC)46 (49%)89 (65%)CT appropriate (% of CT at TU/MTC)77 (83%)104 (76%)

Abbreviations: CT = Computed Tomography; IQR= Interquartile Range; MTC = Major Trauma Centre; TU = Trauma Unit.

We have demonstrated room for improvement in paediatric CT trauma imaging appropriateness across the network, but this is not significantly different between the MTC and TUs. However, time to initial trauma CT was significantly shorter in the MTC.
1690 Can triage based interventions reduce length of stay in a paediatric emergency department? A literature review
Authors: Heyningen Carl Leith van
Published: December 2022

Aims, Objectives and Background

In a busy paediatric emergency department triage decisions are critical to patient flow (see figure 1). In addition to sorting patients by acuity the initiation of early interventions at triage is pivotal. Effective use of triage has the potential to significantly reduce lengths of stay.1,2

Method and Design

Adhering to PRISMA guidelines, we utilised the key words ‘children’, ‘triage’ and ‘length of stay’ to search the MEDLINE and COCHRANE databases for relevant studies. Inclusion and exclusion criteria allowed a focused interrogation of the literature over the last two decades. Bibliographies & specialist journals were also searched to prevent important omissions.

Results and Conclusion

Nine studies (two randomised controlled trials, seven non randomised) were found. Interventions included; reallocated staff for triage, a paediatrician in triage and a series of triage nurse initiated treatments, investigations and protocols. Average reductions in emergency department length of stay ranged from four to forty four minutes per patient.

The common principle identified was early decision making. Statistical significance was demonstrated with few exceptions. Estimates of bias were low. The quality of evidence was high.

Limitations included; uneven benefit (e.g. whilst overall length of stay was reduced, some patients waited longer) and over treatment. Triage nurse initiated treatment stood out as as having the most impact with the least additional cost. There were no adverse incidents.

Triage based interventions are an important strategy in reducing the length of stay for children attending an emergency department. Doing so represents a proactive step in tackling the growing problem of overcrowding in the paediatric emergency department.

References

Haybarker B (2015). Reducing Emergency Department Length of Stay by System Change. Walden Dissertations and Doctoral Studies [Accessed 27/7/21]

RCEM Tackling Emergency Department Crowding December 2015 [Accessed 27/7/21], Available at https://rcem.ac.uk/wp-content/uploads/2021/10/ED_Crowding_Overview_and_Toolkit_Dec2015.pdf
1767 A survey to define the pre-hospital blood resuscitation practices of UK Air Ambulances
Authors: Barnard Ed , Green Laura , Woolley Tom , Stanworth Simon , Cardigan Rebecca , Smith Jason
Published: December 2022

Aims, Objectives and Background

The use of pre-hospital blood components in the early resuscitation of patients with life-threatening bleeding is becoming more common. Understanding the national utilisation of pre-hospital blood is key to developing research strategies in these systems. The aim of this study was to report the blood resuscitation practices of UK Air Ambulances (AAs).

Method and Design

Two sequential surveys were emailed to all UK AAs using the REDCap (research electronic data capture) system. Data were collected for 12 months during 2019 including: number of patients transported, timings, products carried, and number of patients transfused by aetiology. Data are reported as number (percentage), and mean (± standard deviation).

Results and Conclusion

Nineteen (95.0%) AAs responded, and transported a total of 12,170 patients to hospital during 2019. The mean pre-hospital time (999-call to hospital arrival) was 92.2 (±18.6) minutes. 18 (94.7%) AAs routinely carried blood products, including combinations of red cells, thawed plasma, freeze-dried plasma, and fibrinogen concentrate, table 1. The mean units of red cells and plasma carried were 2.6 (±0.9) and 3.0 (±1.1) respectively.

709 (5.8%) adult patients received a prehospital transfusion, of which n=669 (94.4%) had a traumatic aetiology; n=384 (57.4%) and n=183 (27.4%) were transfused ≥2 and ≥4 units respectively. Forty adults received prehospital blood for non-traumatic aetiologies, including: n=18 vascular, n=10 gastrointestinal, n=6 obstetric, n=6 other. In addition, n=24 paediatric patients received a prehospital transfusion; n=23 (95.8%) following trauma.

Fifteen (79.0%) UK AAs surveyed wanted to take part in future research investigating the effectiveness of whole blood transfusion.

Abstract 1767 Table 1

Blood component combinations carried by UK Air Ambulances in 2019, n=19

Blood component combinationsNumber of Air Ambulances (% of total)Red cells and freeze-dried plasma7 (36.8%)Red cells and thawed plasma*6 (31.6%)Red cells only3 (15.8%)Freeze-dried plasma only1 (5.3%)Red cells in thawed plasma (RCP)**1 (5.3%)No products1 (5.3%)

* One air ambulance carried fibrinogen concentrate in addition to a combination of red cells and thawed plasma. ** RCP was being carried as part of a feasibility trial during 2019.

This survey defines current pre-hospital blood transfusion practice in the UK. The majority of AAs carry a combination of red cells and plasma, which are predominantly utilised following traumatic injury. Over three-quarters of UK AAs showed interest in participating in future whole blood research.
1790 Longitudinal coagulation profiles in patients presenting with acute severe traumatic brain injury (TBI): A prospective observational study
Authors: Barrett Liam , Manktelow Anne , Thomas William , Disegna Arthur , Needham Ed , O’Leary Ronan , Boyle Adrian , Curry Nicola , Stanworth Simon , Newcombe Virginia
Published: December 2022

Aims, Objectives and Background

Patients who have sustained a traumatic brain injury (TBI) can have disturbances in coagulation that are distinct from other traumatic bleeding states.1 Coagulopathy is a risk factor for exacerbation of the primary injury, and these patients have less favourable outcomes and increased mortality compared to non-coagulopathic patients.1 Little is known about the longitudinal coagulation changes following TBI.

The aim of this pilot study was to investigate the coagulation profiles of patients presenting with severe TBI over the first 7 days following injury.

Method and Design

Design: Prospective observational study

25 patients presenting to an UK major trauma centre with TBI between August 2021-March 2022 were recruited <24 hours following injury. Professional and family consultee assent was gained and serial blood samples were collected up to three times per day up to day seven.

Coagulation was assessed using thromboelastographs (TEGs) and conventional coagulation tests including Hb, Plt, PT, aPPT and fibrinogen. Pre-hospital, clinical, laboratory and imaging data were collected during the patient admission.

Coagulopathy was defined as having an INR >1.2. The longitudinal changes in the coagulation parameters were plotted for the first seven 7 days and graphically represented. This is a pre-liminary analysis.

Results and Conclusion

25 patients with severe TBI (GCS <12) were recruited. Patients were stratified by their admission INR. 18 patients had an admission INR <1.2 (62% n= 18), and 7 had INR >1.2 (38% n=7). 7 patients who did not have INR >1.2 on their first admission blood test later developed coagulopathy (with an INR >1.2).

Further exploration of the trends seen in conventional coagulation tests and TEG’s over time is required and to understand how these changes correlate to the clinical and imaging findings. The utility of viscoelastic studies such as TEG’s in the assessment of TBI associated coagulopathy remains unclear.
1754 A thematic analysis of Twitter posts pre and post-publication of CRASH-3 trial results using Bloom’s Digital Taxonomy. Examining how social media theories impact knowledge translation
Authors: Bhullar Sukhbir Singh , Ahmed Khaleel
Published: December 2022

Aims, Objectives and Background

The purpose of this study is to unpack the cognitive dimensions of learning and the subjective internalisation that resulted from Twitter activity by investigating the following research questions: 1) What types of information were shared on Twitter pre and post-publication of the CRASH-3 trial? and 2) Did this information signify knowledge translation? This topic is important because translation of medical research into medical practice can take up to 20 years and Twitter-aided knowledge translation has the potential to shorten this. This study is the first to analyse tweets thematically through two methods, including Bloom’s Digital Taxonomy (BDT), bringing the realities of Twitter users to the foreground.

Method and Design

Pre-publication tweets (n=92) and post-publication tweets (n=742) were analysed using 1) Braun & Clarke’s six-step thematic analysis framework and 2) BDT. The highest-order thinking skill (HOTS), during BDT analysis, was assigned following a consensus meeting between two independent coders.

Abstract 1754 Table 1

BDT HOTSPre-Publicationn (%)Post-Publicationn (%)Remembering80 (86.96%)388 (52.29%)Understanding7 (7.61%)185 (24.93%)Applying1 (1.09%)30 (4.04%)Analysing0 (0%)9 (1.21%)Evaluating3 (3.26%)62 (8.36%)Creating1 (1.09%)68 (9.16%)

Results and Conclusion

Eight overarching themes emerging from the pre-publication phase: emotion and feeling (90.21%), hashtagging (40.21%), tagging (26.09%), education-related information (10.87%), research-related information (9.78%), conference (7.61%), statement (3.26%) and poll (2.17%). 16 overarching themes emerged from the post-publication phase: hashtagging (56.06%), tagging (36.79%), article posting (23.05%), emotion and feeling (21.83%), education-related information (19.54%), summarising (14.42%), notification of results (9.57%), media outlook (7.01%), conference (6.74%), commenting (6.06%), open questions (5.26%), judging (4.99%), research-related information (4.04%), recommending (1.75%), quoting (1.48%) and comparing trials (0.40%). Some tweets applied to more than one category of themes.

There was an increase in HOTS during the post-publication phase, signifying an increase in the cognitive dimensions of learning and the subjective internalisation of information. This was likely due to the increase in social media activity and information sharing following the release of trial outcomes. These findings support the role of Twitter, through the social capital model, in facilitating higher-order learning.
1683 Clinical impact of a novel ambulatory computed tomography coronary angiography pathway for patients at a moderate risk of suspected acute coronary syndromes
Authors: Buglass Verity
Published: December 2022

Aims, Objectives and Background

We implemented a novel ambulatory computed tomography coronary angiography (CTCA) pathway as an alternative to inpatient stay when resolving uncertainty surrounding acute coronary syndrome diagnosis in ‘moderate risk’ patients. Eligible patients were identified automatically, and recommendations ‘pushed’ to the clinician. This novel pathway aimed to reduce the length of stay and pressure on hospital resources. We investigated the uptake of this service and its effects on patient outcomes including length of stay and the use of percutaneous coronary intervention (PCI).

Method and Design

We conducted a retrospective, single-centre service evaluation. Patients were eligible for CTCA if they were moderate risk with T-MACS; troponin <99th percentile; no acute electrocardiogram ischaemia.

Data were collected contemporaneously using the T-MACS app as part of routine clinical care for consecutive moderate-risk patients pre- (June 2016 – December 2018) and post-implementation (January 2018 – October 2020) of ambulatory CTCA. The primary outcome was adherence (eligible patients who received an ambulatory CTCA). Secondary outcomes included location and length of stay, time to CTCA, and PCI. We summarised data using descriptive statistics.

Results and Conclusion

We identified 1,341 patients eligible for ambulatory CTCA (524 pre-implementation of pathway; 817 post-implementation; 820 [61%] male; mean age 57 [SD 14]). Pre-implementation, 46.6% (n=244) of these patients were admitted to the Ambulatory Care Unit (ACU). Post-implementation, 32% (n=258) were admitted to the ACU; only 7 (1.3%) eligible patients received ambulatory CTCA after implementation of the service. A further 25 ‘moderate risk’ patients received an inpatient CTCA. The median time to ambulatory CTCA from admission was 1 (IQR 0.75–3) day. Five (71.4%) ambulatory CTCAs were abnormal, identifying coronary artery disease. Three patients with abnormal CTCA underwent PCI; only one followed the ambulatory CTCA pathway.

Abstract 1683 Figure 1

Conclusions

Clinicians continued to admit patients to inpatient areas, indicating suboptimal utilisation of the pathway. Future work should focus on identifying barriers to adherence.
1559 Background noise in an Emergency Department: an observational study from staff and patient perspectives
Authors: Coats Timothy , Emar Murad , Smith Ella
Published: December 2022

Aims, Objectives and Background

Noise is a contributing factor to miscommunication, which may be exacerbated by wearing personal protective equipment. There has been little research on noise in the Emergency Department (ED).

We aimed to (1) identify the noise levels experienced by staff and patients in different areas of an emergency department over the 24-hour cycle, (2) examine the impact of cubicle doors on the background noise experienced by the patient, and (3) assess the impact of monitor alarms on staff and patient noise levels.

Method and Design

Using a standardised protocol, an observational study monitoring of staff and patient experience of noise was carried out in 3 areas of the ED (a resuscitation room, an area of patient cubicles with solid doors and an area of patient cubicles with curtains).

The overall distributions of noise levels in each area were described and circadian variation plotted. The proportion of time that background noise was above key cutoff values known to impair communication was calculated (45dB and 65dB).

Non-parametric methods were used to compare: (1) a patient cubicle with curtains compared to a solid door, (2) having the door open or closed, and (3) staff and patient exposure a monitor alarm.

Abstract 1559 Table 1

AreaOverall noise level (dB).Median (IQ range)Proportion of time >45dB(raised voice)Proportion of time >65dB(shouting)Blue Patient Cubicle (curtain)45 (41 – 51)51%2%Red Patient Cubicle (door)41 (37 – 47)30%2%ER Patient Cubicle (door)50 (49 – 54)100%6%Blue Staff Desk53 (48 – 58)88%7%Red Staff Desk55 (51 – 60)96%7%ER Staff Desk50 (45 – 56)76%5%

Results and Conclusion

In a large urban teaching hospitalEmergency Department noise was greater than 45dB for staff between 76% and 96% of the time (30% to 100% for patients). There was little difference across the 24hr cycle. A door decreased the noise experienced by patients, but only if left closed. In the resuscitation rooms monitor alarms were much louder for patients than for staff.

Noise levels likely to impair communication are present in the ED for most of the time. Staff awareness and improved design of both buildings and equipment might mitigate this negative acoustic environment.
1490 Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM)
Authors: Price James , Lachowycz Kate , Steel Alistair , Moncur Lyle , Major Rob , Barnard Ed
Published: December 2022

Aims, Objectives and Background

Pre-Hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre-hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic – termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM.

Method and Design

A retrospective observational study of consecutive trauma patients ≥16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95%CI)), p-value.

Results and Conclusion

In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs – 90.2% and 87.4% respectively, OR 1.3 (95%CI 0.7–2.5), p=0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt.

In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.
1695 Which clinical features best predict occult scaphoid fracture? A systematic review and meta-analysis
Authors: Coventry Laura , Oldrini Ilaria , Novak Alex , Dean Ben , Metcalfe David
Published: December 2022

Aims, Objectives and Background

Scaphoid fractures require early identification to avoid complications such as painful non-union, avascular necrosis, and chronic wrist pain. Unfortunately, plain radiographs are insufficiently sensitive and so patients may require immobilisation and further imaging (e.g. MRI) despite normal initial radiographs.

The aim of this systematic review was to determine which clinical features best predict the presence of an occult scaphoid fracture that warrants immobilisation and further imaging.

Method and Design

A systematic review of diagnostic test accuracy studies was undertaken. All study designs were included if they evaluated predictors of scaphoid fracture amongst patients with normal initial scaphoid radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Depending on the number of studies, data were presented as individual data points, ranges, or meta-analysed by fitting either univariate random effects or multi-level mixed effects logistic regression models.

Results and Conclusion

Eight studies reported data on 1,685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 7.3%. The most accurate predictors of occult scaphoid fracture were pain with supination against resistance (sensitivity 100%, specificity 97.9%, LR 45.0 [95% CI 6.5–312.5], supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR 3.7 [95% CI 2.2–6.1]), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR 2.3 [95% CI 1.8–3.0]), and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR 2.0 [95% CI 1.2–3.2]). The absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1, specificity 48.4, LR- 0.2 [95% CI 0.4–0.7]).

In conclusion, no single feature can satisfactorily exclude occult scaphoid fracture. However, a number of clinical findings significantly affect the pre-test likelihood of fracture. Future work should determine whether combinations of clinical findings can be used to guide which patients require immobilisation and further imaging despite normal initial radiographs.
1704 Feasibility of implementing a 0–2 troponin algorithm in routine clinical practice
Authors: Ford Sarah , Krishnanandan Sarah , Collinson Paul
Published: December 2022

Aims, Objectives and Background

Recent guidelines for Acute Coronary Syndrome have recommended rapid diagnosis based on repeat sampling at 2 hours from admission. We investigated the feasibility and diagnostic equivalence of repeat measurement at 2 hours by comparing the diagnostic classification achieved by measurement at 0 and 2 hours with a delta value of <=3 between samples to measurement at 0 and 3 hours and a delta of <=7ng/L between samples.

Method and Design

From August to November 2021 all patients with chest pain where a diagnosis of acute coronary syndrome (ACS) was considered had a diagnostic protocol of measurement of cardiac troponin T (cTnT) on admission and at 2 and 3 hours from admission. Requests and results were extracted from the laboratory information system including date and time of result. Data was transferred to a relational database (Access, Microsoft corp) for analysis. Non-parametric statistics were used throughout using the Analyse It.(www.analyse-it.com) add in for Excel.Cardiac troponin T (cTnT) was measured by the Roche high sensitivity cardiac troponin T assay hs-cTnT (Roche diagnostics), range 3 – 10,000ng/L, 10% CV 13ng/L, 99th percentile 14 ng/L.

Results and Conclusion

728 sets of serial samples where obtained on 711 patients, 40.1% female median age 61.8 years,(interquartile range 50.6–75). Comparison of classification is shown in table 1. Overall agreement was good but there were 6 cases where a positive 3 hour delta occurred with a 2 hour delta of 3 or less. 4 had values exceeding the 99th percentile on the admission sample so would have been retained for further investigation. The remaining 4 patients had co-existing clinical conditions that required further investigation.

Abstract 1704 Table 1

ClassificationDelta ≤3 at 2 hDelta >3 at 2 hDelta ≤7 at 3 hours55837Delta >7 at 3 hours635Abstract 1704 Figure 1

Conclusion

The routine use of serial sampling at admission and 2 hours was clinically safe and resulted in the same clinical decisions in the context of the busy ED environment for the population served by the hospital.
1337 Evaluation of a trauma unit bypass tool in predicting major trauma
Authors: Freshwater Els
Published: December 2022

Aims, Objectives and Background

In order to direct patients to specialist Major Trauma Centres (MTCs), triage is performed at the scene of an incident to evaluate the extent of a patient’s injuries. The most severely injured patients are then transported directly to an MTC, even if there is a closer ED. This process is known as ‘Trauma Unit Bypass’ (TUB) and decision support tools are provided for use by ambulance service providers. This study aims to evaluate a tool in current operational use and suggest amendments which may improve its performance in clinical practice.

Method and Design

Data from a period of 12-months (1065 cases) were used to evaluate the performance of a TUB tool used in an English ambulance service. Data were sourced from the Trauma Audit and Research Network (TARN) and ED records and case reviews were performed to extract the required information. Statistical analysis was performed to evaluate the accuracy of the tool in identifying major trauma, defined as an Injury Severity Score (ISS) greater than 15. Further analysis was undertaken to make recommendations for alterations to the tool

Results and Conclusion

The sensitivity of the Wessex TUB is 51.3% and the specificity is 71.3% which makes the tool a poor predictor of major trauma. The tool could be improved by altering thresholds for vital signs (blood pressure and Glasgow Coma Scale) and by providing clarity around the injury findings.

This study provides the first full evaluation of this tool in clinical practice and makes some recommendations to improve performance. This could lead to more accurate identification of patients who have suffered major trauma and ensure they are transported to an appropriate specialist centre. However, it was identified that ISS>15 may not be the most useful outcome measure and it is recommended that a new definition is developed which more accurately describes need for MTC input.
1397 ’I don’t have time’: strategies for increasing research engagement in emergency department clinicians
Authors: Jarman Heather , Halter Mary , Moss Phil , Seel Claire
Published: December 2022

Aims, Objectives and Background

Clinicians who engage in generating research knowledge are more likely to implement findings in practice leading to better patient outcomes. Having an emergency department (ED) culture that gives significance to research is an important factor in supporting clinicians to develop the skill and ability to participate and perform research.

In 2018 the ED at St George’s Hospital, London introduced an embedded research group with a dedicated leadership position, bringing together research delivery staff and clinical academics to increase the research culture in the department. This study aimed to investigate the impact of this model on research engagement amongst the ED clinical multi-disciplinary team.

Method and Design

A case study design approach was used involving:

A registry of the research-related initiatives undertaken in the department

Analysing the metrics of engagement in research activities by clinical staff, including number of publications and academic training uptake

Data were collected between April 2018 and March 2022.

Results and Conclusion

Registry data show 41 distinct initiatives established in the time period led or delivered by the research group. These included face-to-face teaching, publication writing support, a research internship program and small grant funding. Research outputs (publications or conference abstracts) showed a 23-fold increase from two in 2018 to 47 in 2021.

The project to develop a research culture in ED has had a positive effect on both type and number of research-related activities across all clinical staff groups. This case study illustrates how research activities delivered close to clinical practice under visible, focused clinical research leadership can increase research engagement. Challenges of a clinically complex context were overcome by embedding a multidisciplinary clinical research unit, linking research delivery with clinical academic development. This model could be replicated in other settings.
1718 Another CT aortogram request? A 1 year retrospective case note review of all ED-requested CT aortograms
Authors: Manouchehri Shahab , Wilson Sarah , Ticehurst Francoise
Published: December 2022

Aims, Objectives and Background

Acute aortic pathologies have a high mortality rate and can be difficult to diagnose in the Emergency Department (ED). We wanted to know what our local positive diagnosis rate was from ED-requested CT aortograms (CTA).

Method and Design

The radiology department provided a list of all CTA requested by ED during 2019. A retrospective notes review was conducted using the ED notes to identify diagnoses of acute aortic pathology and other positive diagnoses. Our ED saw approximately 90,000 adult patients in 2019.

Results and Conclusion

201 CTA were requested by ED in a single year (2019).

5 (2.4%) scans diagnosed acute aortic syndrome (AAS), with an additional 3 scans that identified thoracic aortic aneurysm without AAS.

13 (6.5%) abdominal aortic aneurysms were identified of which 2 had ruptured.

In addition, 24 (11.9%) patients had non aortic pathologies identified from the scan (6 gallstones, 3 pneumonia, 3 renal colic, 2 metastatic disease, 2 pancreatitis, 2 pulmonary embolism, 6 ‘other’ diagnoses).

Of those with confirmed AAS, only one had an ADD-RS (aortic dissection detection risk score) of 2 (>2 recommend straight to CTA), four had a score of 0 or 1 and none had a D-dimer recorded.

It is sometimes perceived that CTA has a low diagnostic yield, but 23% of patients scanned in our cohort were able to have a positive diagnosis made after their scan, with approximately half of identified pathology being non-aortic.