bluuebunny/crossref_metadata_2025 huggingface dataset:
AGE-ADJUSTED D-DIMER THRESHOLD: RAISING THE BAR ON VTE DIAGNOSIS
Authors: Jaconelli T , Eragat M , Crane S
Published: November 2015

Objectives & Background

The standard work-up for patients suspected of having venous thromboembolism (VTE)-specifically deep vein thrombosis (DVT) and pulmonary embolism (PE) involves risk stratification, usually with the Wells score. This method of risk stratification dictates that patients who are deemed to have a low pre-test probability of VTE should have a serum D-dimer level taken. D-dimer values correlate positively with increasing age, this work looks at whether an age adjusted value can be used to safely exclude VTE.

Table 1

2x2 Table for Standard D-dimer Value

VTE PositiveVTE Negative Old D-dimer Positive25157182Old D-dimer Negative0377377255345592x2 Table for Age-adjusted D-dimer ValueVTE PositiveVTE Negative New D-dimer Positive25112107New D-dimer Negative0422422 25534559

Methods

We designed a study protocol which aimed to identify the clinical outcomes of all patients at York Hospital who had a D-Dimer level measured in ED. Using retrospective data we estimated the proportion of patients who had investigations for suspected VTE, and the results of these investigations. The primary outcome was the diagnosis of VTE. We derived data for the sensitivity and specificity D-Dimer tests (in the diagnosis of VTE) using the current cut-off (230 ng/ml) and also for a proposed new cut-off 5× the age in those over 50 and 250 ng/ml up to the age of 50.

Results

From 01/11/13 to 21/03/14, 682 patients underwent D-dimer testing for suspected VTE (256 DVT and 426 PE). Those with a high wells score were excluded from analysis leaving 559 patients (156 DVT and 403 PE). Of this group 12 were diagnosed with DVT on ultrasound and 13 diagnosed with PE on CTPA; the rest had alternate diagnoses. 25 patients had positive D-dimers with the age adjusted value i.e. there were no false positives. With the age adjusted value 17 ultrasound scans would have been avoided and 28 patients would have PE safely ruled out.

For the standard D-dimer the sensitivity was 100% (86.28–100 95% CI), specificity was 70.60% (66.53–74.43 95% CI) and the NPV was 100% (99.03–100). For the age adjusted value the sensitivity was 100% (86.28–100 95% CI), specificity was 79.03% (75.32&–82.40% 95% CI) and the NPV was 100% (99.13%–100% 95% CI).

Conclusion

The data shows that in patients suspected of having a VTE with a low pretest possibility, an age adjusted D-dimer increases the specificity of the test with no effect of the sensitivity when compared to the conventional D-dimer threshold. In practice this means that more patients can be safely discharged from the emergency department without further, unnecessary investigations. This may result in reduced hospital admissions, radiology time and iatrogenic harm from CTPA.
THE IMPLEMENTATION OF MASSIVE HAEMORRHAGE PROTOCOL (MHP) FOR THE MANAGEMENT OF MAJOR TRAUMA:A TEN YEAR,SINGLE CENTRE STUDY OF PATIENT OUTCOMES
Authors: Mothukuri R , Battle C , Guy K , Mills G , Evans PA
Published: November 2015

Objectives & Background

Massive haemorrhage in major trauma is one of the leading causes of death. Haemostatic failure leads to uncontrolled blood loss and reduced tissue perfusion resulting in coagulopathy. Recent studies support the use of early component replacement. In the UK, trauma centres have adopted the use fresh frozen plasma, platelets and packed red cells in the ratio of 1:1:1 to improve and maintain normal haemostatic function. In 2011, MHP was introduced to improve links between the trauma team and transfusion team and accelerate the issue of blood products.Our aim is to evaluate and compare the outcomes before and after implementation of MHP.

Methods

All trauma patients admitted to the Emergency Department (ED) of a large teaching hospital in South Wales between 2005 and 2015 were studied, using the data collated for submission to the Trauma Audit and Research Network (TARN). Demographic variables included sex, age, Injury Severity score (ISS) code, PS14 and injury mechanism; management variables included whether the trauma team was activated, whether Tranexamic acid (TXA) was given and whether the MHP was instigated. Outcome variables included hospital and critical care length of stay and mortality. Patients were divided into two groups; those admitted before the introduction of MHP(pre-MHP) and those admitted after its introduction (post-MHP). Differences in the data were analysed using the Fisher Exact test (categorical variables) and student's t-test (continuous variables).

Results

A total of 832 patients were included in the analysis,446 in the pre-MHP and 386 in the post-MHP group.There were no significant differences in patient age, sex, PS14 or injury mechanism. The pre-MHP group had a significantly higher ISS (p=0.02). There was no difference in the activation of the trauma team between the two groups. There was no difference in the mortality between the two groups. Tranexamic acid and the MHP were used in a significantly greater number of cases in the post-MHP group. Hospital length of stay and the critical care length of stay were significantly reduced following the introduction of the MHP (both p<0.001).

Conclusion

We demonstrate,a well-defined MHP and the use of TXA contributed to reducing patient length of stay both in critical care and in hospital.Further data analysis is needed to show correlation between use of component replacement and improved outcome.

Figure 1

Results.
AGE IS ONLY A NUMBER?—TIME IN THE EMERGENCY DEPARTMENT (ED)
Authors: Liston P , Conyngham G , Brady M , Byrne P , Gilligan P
Published: November 2015

Objectives & Background

The average age of patients occupying the ED in Beaumont ED is seen to be rising and this fact coupled with an aging population points to potential future demand pressures on ED departments. This research looks at the changing age profile of patients that attend the ED and the relationship between age and waiting time or Patient Experience Time (PET) in the ED. This research is part of a wider research project looking to simulate patient flows through the ED.

Methods

We analysed a 10 year dataset from the ED at Beaumont Hospital to study trends in average patient age and PETs. We then applied linear regression to the 2013 data, (60,000 patient visits to the ED), to examine the relationship between age and PET. Three separate models were developed with PET, time from admission to first medical and time from bed request to being admitted to hospital as the respective dependent variables. These models also controlled for triage type, patient admitted (Yes/No), number in ED and other factors.

Results

The average age of ED patients has risen from 43.8 years in 2005 to 48.2 years in 2014 (Figure 1). These older patients have a greater likelihood of admission and in addition experience longer waiting times in ED (See Figures 2 and 3). Using a regression analysis, age was seen to contribute an extra half an hour in PET per 10 year increase. Age had, in contrast, a negative effect on time to first medical with lower waiting times for older age groups. In the final model, predicting the patient time from bed request to being admitted to hospital, age emerged as the most significant factor, with older patients experiencing significantly longer waits. Figure 4 demonstrates these findings, in particular the significant proportion of PET for older patients due to bed requests.

Conclusion

Age has a significant effect on patient experience time in the ED. The time to first medical care is mainly driven by triage category, but even controlling for this, older people receive care faster. However, subsequently older patients spend longer in the ED and this is due to longer waits for older patients for a hospital bed. The result is an ED populated with elderly boarders. With an ageing national population in Ireland this research emphasises a need to plan for the future healthcare of elderly patients within and beyond acute hospitals.

Figure 1

Average Age of Beaumont ED Attendees.

Figure 2

Age profile of Beaumont ED Patients (Admitted and Discharged).

Figure 3

Average Patient Experience Time per Age Band for Admitted and Discharged Patients.

Figure 4

Waiting Times by Age Band (2014).
WHY DO ADULTS WITH PALLIATIVE CARE NEEDS PRESENT TO THE EMERGENCY DEPARTMENT?
Authors: Green E , Harris T , Tempest E , Brierley W , Riley B , Sattar H , Ward S
Published: November 2015

Objectives & Background

Policy in many countries focuses on preventing hospital admissions at the end of life. However, little attention has been paid to the role of the emergency department (ED) in this regard, despite the fact that a high proportion of hospital admissions among patients with palliative care needs originate in the ED. This paper aims to improve understanding of ED use within a palliative care context, which will subsequently facilitate decision-making around the constitution of an avoidable ED presentation.

Methods

The initial phase of this service evaluation comprised a literature review. Subsequently, the electronic records of all patients known to the specialist palliative care team at Whipps Cross hospital presenting to the ED over a three-month period were evaluated prospectively (n=112). These quantitative data were analysed using descriptive statistics. Finally, semi-structured interviews with seven patients from this sample were conducted and thematic analysis was applied.

Results

105 patients made 112 presentations to the ED. 53% were female; the mean age was 73. The two most common presenting complaints were shortness of breath (35%) and pain (28%). There is currently no internationally agreed definition of an appropriate ED presentation; therefore one was established for the purpose of this project. 76% of presentations were deemed to legitimately require ED management.

Findings from the qualitative phase highlighted a significant lack of awareness of the availability of alternative services among patients. This often resulted in disjointed, inadequate care, and appeared to be complicated by the ‘postcode lottery’ phenomenon. Patients reported valuing continuity of care, which often resulted from being known to specialist services. Difficulties with data sharing between ED and specialty teams were observed, often delaying management, and communication between primary and secondary care was deemed problematic. Patients perceived the ED to be a safer environment than primary care, capable of providing a higher level of reassurance.

Conclusion

This service evaluation explores the reasons for ED presentation among patients with palliative care needs from both the perspectives of healthcare professionals and service users. Findings challenge commonly held misconceptions regarding the presence of palliative patients in the ED, and direct potential changes in future service provision.
ROMANCING THE STONE: MORE DIAGNOSES OF RENAL COLIC DOES NOT EQUAL MORE CASES NEEDING INTERVENTION. A RETROSPECTIVE ANALYSIS
Authors: Sharpe D , Gidwani S , Clough R
Published: November 2015

Objectives & Background

In 2008 and 2009 the British Association of Urological Surgeons and the Royal College of Radiologists issued recommendations that non contrast CT scanning should be the first line imaging modality for the diagnosis of renal calculi in the acute setting. More than 6 years later we hypothesise that this has led to a large increase in CT scans and thus radiation exposure, without demonstrating and increased need for surgical intervention.

Methods

All CT scans of the abdomen or Kidneys, ureters and bladder ordered by the ED from 2008 to 2013 were collated via the Picture Archiving and Communication System. This data was analysed and all cases not relating to investigation of urolithiasis were disregarded. A final list was interrogated for gender, age and previous diagnosis of stones. Annual attendance rates to the ED and the number of litholopaxy procedures were also collected.

Results

1208 CT scans were performed to diagnose renal colic in this 6 year period. The number of scans performed annually rose from 51 in 2008 to 252 in 2013. 35% were women and of those women a median of 70% annually were under the age of 50. 23% of patients had previously confirmed urolithiasis. Of those a median of 64% annually were under the age of 50. Despite ED attendances rising in this period by 13.5%, the proportion of patients scanned for stones disease rose from 0.05% to 0.2%. The number of litholopaxy decreased from five to one.

Conclusion

These results show that despite an increased proportion of patients receiving a CT scan since 2008, the number of patients requiring intervention has actually decreased. Additionally, repeated scanning of those under the age of may be causing significant cumulative radiation exposures. We propose a prospective trial is needed to use more appropriate imaging for this group of patients. In addition, refinement of the clinical question posed by patients with presumed urolithiasis might lead to the use of a different imaging modality such as ultrasound.
HOW DO OLDER PEOPLE WITH ACUTE CORONARY SYNDROMES PRESENT? THE EXPERIENCE OF A DEVELOPING COUNTRY
Authors: Hassanali Z , Sammy IA , Paul JF , Sinanan R
Published: November 2015

Objectives & Background

Acute Coronary Syndrome (ACS) is a major cause of mortality in Trinidad and Tobago. Previous studies have demonstrated differences in the presenting symptoms between older and younger patients with ACS. However, to our knowledge, no such work has been done on older patients in the developing world.

The aim of this study was to determine the differences in the reported symptoms of ACS between the older patients (age≥65) and younger adults (age 18–64) in the ED. A secondary objective was to determine if differences in reported symptoms also exist between men and women.

Methods

A retrospective cross-sectional study of all adult patients admitted to the ED of the San Fernando General Hospital with a discharge diagnosis of ACS from August 1, 2012–May 31, 2013 was conducted. Elderly patient symptoms were compared with other adult patients using descriptive and analytic methods. Symptoms were similarly compared between males and females. Symptoms were compared using odds ratios. All results were presented with 95% confidence intervals and ‘p’ values.

Results

The symptoms of 1148 adult patients with ACS were analyzed. The mean age of presentation was 61.6 years (SD12.2). 41.3% of patients were elderly and 47.0% were males. Syncope (OR 2.1; 95% CI 1.1, 3.7), Paroxysmal Nocturnal Dyspnea [PND] (OR 1.3; 95% CI 1.0, 1.7) and orthopnea (OR 1.3, 95% CI 1.0, 1.6) were more likely to be reported in the elderly while chest pain on exertion (OR 0.7; 95% CI 0.5, 0.9) and chest pain in the past 24 hours (OR 0.8; 95% CI 0.6, 1.0) were less likely to be reported in the elderly. Females were more likely to report shortness of breath (SOB) at rest (OR 1.4; 95% CI 1.1, 1.8), PND (OR 1.8; 95% CI 1.3, 2.4), orthopnea (OR 2.0; 95% CI 1.6, 2.7), palpitations (OR 1.7; 95% CI 1.3, 2.2), and nausea (OR 1.5; 95% CI 1.2, 1.9) than males. Chest pain at rest was still the most frequent symptom reported in all groups.

Conclusion

This study demonstrates significant differences in symptoms between older and younger patients as well as between men and women. Clinical assessment of older patients with ACS should be tailored to their common presenting features. Further work is needed to develop a clinical assessment tool for older patients with ACS that accounts for differences in presentation.
VALIDATION OF RISK STRATIFICATION MODELS FOR LONE ACUTE SUDDEN HEADACHE (LASH)—HOW FAR HAVE WE TRAVELLED?
Authors: Binbay A , Chadwick A , Hassan T
Published: November 2015

Objectives & Background

Lone acute sudden headache (LASH) remains a challenging presentation for the emergency physician (EP). Maintaining safe practice and yet balancing the risks and benefits of potential over investigation have generated the development of risk stratification models to help identify patients with serious pathology such as subarachnoid haemorrhage SAH). The Ottawa SAH rule has potential to reduce the need for radiological intervention and lumbar puncture in certain groups of patients but has not been validated in a UK setting.

To validate the Ottawa SAH rules in a UK emergency setting and assess its potential performance.

Methods

A structured data retrieval tool was developed to perform a retrospective medical record review for all patients admitted to the Clinical Decision Units of two Emergency Departments (EDs) with severe headache, over a 12 month period. The Ottawa (OSAH) rules were then applied to this data set.

Results

Of the 1096 patients recruited to the study, 890(81.2%) had a CT scan performed due to a consideration of LASH to exclude SAH. Of patients with a normal CT, only 346 had a lumbar puncture (LP) performed due to patient choice or clinician decision making. A total of 15 patients had SAH confirmed (1.37%) – all on non contrast CT. Applying the OSAH rules would have identified all 15 patients with SAH (100% sensitivity). There was also the potential to decrease the number of LPs performed by 27%, 37% and 44% for each clinical risk tool.

Conclusion

The OSAH rule is a useful adjunct to clinical decision making in patients presenting to ED with LASH in a UK population. The EP can also use data from studies like ours (the largest single centre study in the UK to date) to help in joint decision making with patients to help quantify risk and appropriateness of need for further investigation.
USING A CLINICAL PHARMACIST IN THE EMERGENCY DEPARTMENT
Authors: Henderson KI , Gotel U , Hill J
Published: November 2015

Objectives & Background

UK urgent and emergency care (UEC) services are facing significant increased patient demand alongside a shortage of medical and nursing staff. From the early 2000's pharmacy services have been developing to support service provision in EDs with similar roles to in-patient clinical pharmacists but clinical pharmacists skills are still underutilised in UEC provision. To optimise ED skill mix and support medicines management a ED role was developed. Such a service would ensure medicines reconciliation for high risk ED patients, transcription of drug charts, increase use of patients own drugs (PODs) with potential cost savings, provide review for changes in medicines (including advice, patient information, antibiotic stewardship, high risk medicines) and direct support for transfer of changed medication and medicines information on discharge from ED (liaison with GP, community pharmacist, care homes) as well as reducing reattendance due to non-adherence.

Methods

Pharmacy secured funding for one whole time equivalent clinical pharmacist. The clinical pharmacy service (CPS) ran from 29.09.14–31.03.15, with hours 13–21.30 Fri/Sat/Sun, 12–18:00 Mon & 18–21:30 Mon-Fri.

This review aims to demonstrate the impact of a clinical pharmacist in the ED.

1. Quantify operational workload undertaken by the clinical pharmacist(s)

2. Identify drugs staff request support/information for

3. Identify main reason for drug support/information request

Activity and specific drug data were collected for every shift. A standard operational data collection proforma was piloted and amended for use.

Results

149 shifts (802hrs) were completed. 10 patients on average per shift, (five tasks completed in 32 mins). Staff requested support/information for 388 individual drugs. The most common reason - safety to prevent an ADR 60% followed by efficacy 32%, length of stay 10%, compliance/concordance 16%. Six percent (24/388) were for safety in relation to an ADR. Most requests where for medicines acting on the CNS 26%, CVS 23% or to treat infection 21%.

Conclusion

ED Pharmacists ensured medicines quality and safety and released ED clinician time. This was achieved by Key pharmacist safety inputs

1. allergy confirmation, providing a medicines safety barrier supporting safer prescribing in a high risk environment

2. reduction in missed or delayed doses through early DH identification, MR and supply of non-stock medicines

3. avoidance of ADRs

4. provision of specific, timely drug advice
THROMBOPROPHYLAXIS FOR AMBULATORY PATIENTS WITH IMMOBILISED LOWER LIMB TRAUMA: A CLOSED AUDIT LOOP
Authors: Horner D , Ryan A , Bennett P , Gillet A
Published: November 2015

Objectives & Background

Patients with acute lower limb injuries and temporary immobilisation are at risk of subsequent venous thromboembolic disease (VTE). Recent National Institute of Health and Care Excellence has recommended formal risk assessment in the emergency department and consideration of prophylaxis for those considered high risk. Subsequent RCEM guidance has been produced to support decision making in the form of the GEMNet guidelines. Despite these documents, practice remains inconsistent and patients continue to have adverse outcomes.

We sought to evaluate local practice and implement change to improve standardisation.

Methods

A prospective audit cycle over 2 discrete monthly episodes in 2015. Patient episodes coded as lower limb fractures were retrospectively assessed over a 4 week period to collect data on use of the local orthopaedic pathway and national GEMNet pathway. Adherence to local policy was assessed. Following the initial period of assessment, a series of interventions were agreed with local stakeholders in an attempt to standardise care and improve patient experience. The interventions included redesign of the pathway to adhere to GEMNet guidance, local education and launch, electronic patient record discharge prompt/block and orthopaedic engagement. After delivery of the interventions, patient episodes were re-evaluated to ascertain improvement in delivery of care and staff opinion.

Results

During the initial month of evaluation, only 32% (20/62) of applicable patients evaluated had a documented VTE risk assessment. Of these patients, none received thromboprophylaxis as per the local policy. A substantial proportion of these patients (40%) would have been considered eligible under GEMNet guidance. Following launch of the new pathway and delivery of the interventions, 93.1% (54/58) of applicable patients over the month had a documented risk assessment recorded in the medical notes. Of this cohort, 43% (25/58) were considered high risk by GEMNet guidelines and accordingly prescribed thromboprophylaxis. No clinical short term complications were encountered on chart review.

Conclusion

A series of interventions including simplification of risk assessment, stakeholder agreement, local education and electronic prompt led to a clear improvement in documented VTE risk assessment for ambulatory patients with temporary immobilisation secondary to lower limb injury.
ARE WE TALKING BUT NOT BEING HEARD?
Authors: Hardy J , Carrington S , Turner C
Published: November 2015

Objectives & Background

Poor communication is at the heart of most complaints within the NHS. Failure to understand what a healthcare professional is saying can lead to confusion, fear, and complaints. We constructed a pilot study to understand the level of patients' comprehension of common statements heard in the emergency department setting.

Methods

Over one week in 2015 we surveyed patients about their understanding of commonly heard medical expressions at a MTC in the W. Midlands. This was a convenience sample (due to team availability), but not restricted to any specific time of day/night.

We identified five statements that represented procedures, processes within hospitals, and diagnosis. The questionnaire was given out after the medical consultation. Following completion an answer sheet was provided along with the opportunity to ask any further questions that there might be. Answers were written, with assistance where needed.

The the data was collated using Excel. Answers to the common statements were divided into three categories; full understanding, partial understanding and no understanding. An a priori sample size of 30 was decided upon, largely because this is the number that our trust feels comfortable with when performing patient experience work. GAfREC approval was given.

Results

29 questionnaires were completed. Only one of our five statements (“you've got a fracture”) was understood by over 50% of the sample.

Statements most poorly understood appear to involve hospital specific process involving acronyms such as ‘You're going to AMU’ (90% had no understanding) and ‘The ITU Reg is going to come and see you’ (76% had no understanding).

Patients understand little of what we say to them and this gets worse the more acronyms we use.

Despite this most patients felt the doctor and the nurse explained things well. This may reflect staff taking the time to explain medical terminology in the context of the patient's specific problem or pathology. Patients and relatives also reported that they were asked if they had any questions.

Conclusion

It is unreasonable to assume patients understand commonly used medical terminology, Although medical terminology may be ubiquitous in a place of work it has the potential to be both profession and location specific. It is easy to forget this. As healthcare professionals we need to communicate using language the patient can understand and allow the patient an opportunity to ask for clarification.
FEASIBILITY AND COMPARISON OF NON-INVASIVE HEMODYNAMIC DEVICES IN THE EMERGENCY DEPARTMENT; USCOM VS NICCOMO
Authors: Green SJ , Hussain S , Hue J , Patel J , Coats T , Sims M
Published: November 2015

Objectives & Background

Within emergency medicine there is a demand for non-invasive techniques to measure patient observations. Within resuscitation of unwell patients, measuring Cardiac Output (CO) and Systemic Vascular Resistance (SVR) is carried out in intensive care environment using invasive techniques. In this study we trialled the use of two non-invasive Cardiac Output monitors to assess their feasibility and agreement. The USCOM (USCOM) is a suprasternal Doppler device that uses ultrasound technology and has been extensively researched within clinical medicine. The Niccomo (Medis) device is a novel biothoracic impedance monitor.

Methods

Patients were recruited as part of the ‘multi-modality monitoring in the emergency department’ trial, University Hospital Leicester NHS trust (UHL). Adult patients with a wide range of clinical conditions presenting to the ED who were able to consent were recruited to the study. Devices were attached as per manufacturer instructions, with standard medical care ongoing throughout the study. Data was analysed using R statistical computation.

Results

215 patients were included in the study with an age range 18–95 years. 93 patients had readings for both modalities. Figure 1 represents a Bland-Altman comparing average CO readings of USCOM vs Niccomo with the global average USCOM reading was considerably lower than the Niccomo device. Figure 2, shows SVR of USCOM vs Niccomo, this again highlighted a large difference between measurements.

Conclusion

This study revealed the Niccomo measured CO and SVR readings similar to the expected range of patients in this study. However, the USCOM revealed a significantly lower reading for CO and a higher SVR reading than the Niccomo. Further work needs to be undertaken to assess the clinical utility of the different methods to measure cardiac output. The study emphasises that different non-invasive methods of cardiac assessment are not interchangeable.
WRITTEN FIRST AID INFORMATION FOR PATIENTS IN THE EMERGENCY DEPARTMENT: A CLUSTER RANDOMISED CONTROLLED TRIAL
Authors: Pallot D , O'Keeffe C , Dawson J , Mason S , Oliver E , Mulligan J
Published: November 2015

Objectives & Background

Patients with minor injuries create a significant workload for Emergency Departments. Each attendance is also an opportunity to deliver health education, and written information is established to be effective. Appropriate first aid may reduce the workload of the Emergency Department, and reduce injury morbidity. It was hypothesised that giving patients written first aid information during an attendance will improve confidence and knowledge of first aid.

Methods

The study was run at the Northern General Hospital, Sheffield, from 15th March to 4th April 2014. Consecutive adult patients attending the ED with eligible presenting complaints between 9am and 8pm were recruited. Patients were selected from those assigned to the minor injuries area of the ED.

The eligible presenting complaints were:

– Limb injuries

– Wounds

– Head injuries

Allocation to intervention and control groups was done by day of presentation based on a computer generated random sequence. Patients in the intervention arm were given written information about first aid produced by the British Red Cross. Both arms also received usual care inlcuding any normal verbal advice and other written information. The initial questionnaire was given to consenting patients in both groups before being seen by a doctor, and before the written information was given in the intervention group. The ED records were used to collect diagnosis and demographic data. Follow up questionnaire was performed at 4 weeks. Re-attendance data was collected from ED records at 3 months. Analysis of confidence was by repeated measures ANOVA and knowledge of individual treatments by binary logistic regression.

Results

293 patients completed the initial questionnaire and 194 (66%) were followed up. There was no effect on confidence in performing first aid on themselves (mean effect 0.321 on a scale of 0 to 10, 95% confidence −0.335 to 0.978). The intervention improved knowledge of limb injuries (p=0.006) and wounds (p=0.032) but not head injuries. The intervention also reduced suggestions to seek medical assistance in the intervention group (p<0.001).

Conclusion

Written information improves knowledge, but does not affect confidence in first aid management of minor injuries. The follow up period was too short to show a change in attendance behaviour and further work should analyse the effect of first aid written information on patient behaviour.
THE COMMUNITY FALLS PATHWAY—AN URGENT CARE INITIATIVE HELPING FALLEN OLDER PATIENTS TO STAY AT HOME
Authors: Hartley E , Holland J
Published: November 2015

Objectives & Background

Many older patients present to ED after a fall. Older patients are more likely to get admitted to an acute bed when they present to the ED than younger patients. Admission is associated with loss of independence, acquired infections and delirium. Length of hospital stay is longer for older patients. Delayed discharge of medically well patients awaiting community care packages is associated with stagnant flow in the ED.

We identified a population of older adults presenting via ambulance following a fall, who were being admitted for physio, OT and social worker assessment from the ED, but did not require inpatient treatment for a medical problem. We proposed that these admissions could be avoided.

Methods

Cross-sector admission avoidance initiative between primary and secondary care, ambulance services and social services in Coventry and Rugby area. Seamless 24/7 pathway developed to provide medical assessment, OT, physiotherapy, social support and emergency equipment to enable a patient to stay at home. We developed a traffic light based assessment system for ambulance crews, and resourced a 24 hour telephone line linked to an Advanced Nurse Practitioner and community care services. The ambulance crew refer to the ANP then get back on the road. The ANP can undertake a home visit to the patient, arrange a home visit from their GP or access an urgent GP appointment or appointments with the Falls clinic or Acute Medicine clinic. In addition to the medical assessment there is access to OT, physio and social care, including a fully stocked 24 hour equipment store.

Results

174 referrals were made in the first 26 weeks of the pathway. 154 patients were enabled to stay at home.

The admission avoidance rate was 88.5%.

6/154 patients self-presented to the local ED within 48 hours of their urgent care intervention.

There were 2 recorded clinical incidents.

Patient feedback has been positive.

Cumulative cost-savings in the first 26 weeks is £248000.

Conclusion

This cross-sector initiative has prevented admissions when the acute trust has been operating under significant bed pressure. This is an easy-to-use, patient centred, safe pathway giving comprehensive care to the fallen patient.

For phase 2 we have developed an ED-based 'Pull-out Pathway' to enable the early discharge of fallen older patients following medical assessment in the ED. This will start in June 2015.

Figure 1
INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: WHAT IS THE INCIDENCE AND HOW DO WE DETECT IT?
Authors: Edwards RG , Kehoe A , Graham B , Smith J
Published: November 2015

Objectives & Background

Inadvertent intra-arterial cannulation (IIAC) is a recognised complication of peripheral cannulation with the potential for severe consequences including limb ischaemia and amputation. Patients presenting to EDs are often complex, frail or obese (known risk factors for difficult cannulation) meaning the overall incidence may be much higher than that suggested by existing evidence.

Objectives:

▸ To report the rate of IIAC in our Emergency Department.

▸ To assess whether blood gas analysis can be used to screen for IIAC.

Methods

A prospective observational study was undertaken over a two week period. Every cannula inserted in the ED during hours of recruitment had blood drawn and blood gas analysis performed. The results were analysed by a senior ED clinician who assessed whether the blood gas values represented arterial or venous blood. Ultrasound assessment was performed on every cannula to confirm placement and, if there was any degree of uncertainty, transduced pressure readings were obtained.

Results

Two IIACs were confirmed out of the 83 cannulae analysed, a rate of 2.4%. Both of these IIACs were detected by the senior clinician interpreting the blood gas. Two further cannulae were incorrectly identified as potentially arterial on the blood gas, but were proven to be venous using ultrasound. Both patients experiencing IIACs had multiple risk factors for difficult cannulation and 44% of all subjects had at least one risk factor.

Conclusion

IIAC occurs more frequently than previously reported in our ED. A high proportion of ED patients have risk factors that make IIAC more likely. Point of care blood gas analysis may be a useful screening tool for detecting IIAC, particularly when used in conjunction with ultrasound +/− transduction. The results of this study justify further research to confirm and extend these observations. Implications for everyday practice within the ED include increased awareness and recognition of IIAC.
THE IMPORTANCE OF UNDERSTANDING JUNIOR DOCTOR PERCEPTIONS OF CONFIDENCE AND COMPETENCE IN RELATION TO THE FEBRILE CHILD
Authors: Ronald D , Martin G , Coats T , Matheson D
Published: November 2015

Objectives & Background

It is important to determine whether trainees have gained a greater belief in their abilities at carrying out a particular skill or knowledge set (confidence), whether they are technically more proficient in putting them into practice (competence) or both. If confidence and competence are not clearly understood it cannot be assumed self-reported outcomes during training are valid. The aim of this work was to explore Junior Doctors' understanding of how they perceive their own performance in respect of managing feverish children.

Table 1

A proposed matrix of perceptions of competence, confidence and safety

Reported CompetenceLowHighReported ConfidenceLowSelf-Perception: UnsafeSelf-Perception: Unsafe or SafeHighSelf-Perception: SafeSelf-Perception: Safe

Methods

Junior doctors (postgraduate year 2) in a children's emergency department were consented to take part in the study following ethics committee approval. Two focus group sessions, utilising a novel focus group design (meta-planning) as a methodology to drive discussion, were undertaken one week apart (9 and 7 participants), to maximise attendance and allow unexplored themes to be discussed further if one session was inadequate. A repeat session for a new group (8 participants) was held one year later using the same methodology.

Results

The focus groups demonstrated that although the junior doctors recognised a difference between confidence and competence they were not able to define it. Despite this difficulty there was general agreement of feeling ‘safe’ in the management of the febrile child at the end of the attachment. The groups also struggled to separate collectively themed categories of skills or constructs into distinct competence and confidence domains (figure one).

Conclusion

A perception of ‘safeness’ is as a concept that may aid self-evaluation and we present a matrix (table) that might be used to examine this and its relationship with confidence and competence. This will be useful for clinical supervisors and educators in Children's Emergency Departments as the concept is evolved from management of the febrile child but it is likely to have much wider use.

Figure 1

Response to question How can I become more confident in dealing with children〈Black Squares〉and How can I become more competent in dealing with children 〈White Squares〉.
A 10-YEAR DEMOGRAPHIC COMPARISON OF MAJOR TRAUMA AS A RESULT OF NON-ACCIDENTAL INJURY VERSUS ACCIDENTAL INJURY IN THE UK
Authors: Davies F , Coats T , Lecky FE
Published: November 2015

Objectives & Background

Non-accidental injury in children is generally understood to have a different injury and age profile from accidental injury. The Trauma Audit Research Network (TARN) in the UK recently compared the demographics of paediatric versus adult trauma. This paper compares accidental with non-accidental major injury in children.

Methods

The national trauma registry of England and Wales – Trauma Audit and Research Network (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals' data was classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons.

Results

In the study population of 14,821 children, 13,695 (92.4%) were classified as accidental injury, 368 as alleged assault (2.5%) and 758 as suspected child abuse (5.1%). Nearly all cases of severely injured children suffering trauma because of suspected child abuse occurred in the 0-5 year old age group (740 of 758, 97.6%). Of all suspected abuse cases, 584 of 758 (77%) occurred in babies under the age of one year. Compared with accidental injury, abused children have higher injury severity scores, particularly as a result of head injury and a three-fold higher mortality rate.

Conclusion

This study highlights that major injury occurring as a result of child abuse has a typical demographic pattern. Abused children tend to be under 12 months of age, with more severe injury, especially head injury. Understanding the demographics of this patient group could help receiving hospitals identify children with major injuries resulting from abuse, and ensure swift transfer to specialist care.
S-KETAMINE SEDATION IN A TERTIARY PAEDIATRIC EMERGENCY DEPARTMENT
Authors: Byrne E , Mulvaney S , Abela N
Published: November 2015

Objectives & Background

To discuss the use of S-Ketamine for minor injuries in a tertiary Paediatric Emergency Department (PED), using a literature review of the topic and retrospective review of the department's first 200 patient's experience.

Methods

A literature review of Ketamine was carried out on procedural sedation using Ketamine in children in the Emergency Department. This was combined with a retrospective audit of Alder Hey Hospital departmental practise of the first 200 patients undergoing this method of sedation. The first 200 patients were cumulatively recorded by the researchers and their case notes reviewed for indication for sedation, dose given, adjuntive medications used and adverse reactions.

Results

There is ample literature data to support the use of ketamine for procedural sedation in the paediatric emergency department. In the audit, 200 patients were adequately sedated using IV ketamine with a mean dose of 1.1 mg/kg and a median dose of 1 mg/kg. The procedures carried out included laceration repair (46%), foreign body removal (17.5%), reduction of fracture or dislocation (29%) and other procedures (7.5%). 40 (19.8%) experienced an adverse reaction, the commonest of which was vomiting (7.9%), followed by airway problems (4.9%) and confusion (2%). 8 (3%) patients required adjunctive medication (ondansetron (6); midazolam (2)).

Conclusion

S-Ketamine is safe to use in the PED for sedation for minor injuries and procedures. However, further studies are needed to determine the correct dose regimen and to determine methods of decreasing adverse events.
THE USE (MISUSE?) OF MONTELUKAST IN WHEEZY PRE-SCHOOL CHILDREN
Authors: Abrahamson E , Abubakar-Waziri H , Wilson A
Published: November 2015

Objectives & Background

The role of montelukast in the rescue treatment of acute wheeze in pre-school children has come under increasing scrutiny. It has gradually entered clinical practice but without robust scientific data to support its use. Our department was an early adopter and we performed this review to compare clinical features and outcome between those treated and those not.

Methods

We performed a retrospective case note review of the management of all pre-school wheezers aged 0-5 years presenting to our Paediatric Emergency Department (PED) over a 12 month period. Cases were identified from the database using the Business Objects Tool©.

Results

391 cases were identified, of which 231 (59%) received montelukast (G1) and 160 (41%) did not (G2). The mean age (months) of cases was similar in G1 32.41 (7–60) versus G2 29.01 (4–59). 191 (82.7%) cases in G1 had at least one previous episode of wheeze vs 108 (67.5%) in G2, p=0.0005.

G1 were more likely to have received montelukast previously 67 (29%) vs G2 22 (13.8%), p=0.0004. They were also more likely to show signs of respiratory distress G1 179 (77%) vs G2 100 (62.5%), p=0.0013. 40 (17%) cases in G1 had no prior history of wheeze. G2 were more likely to receive steroids 38 (23.8%) vs G1 29 (12.6%) p=0.0039.

There was no difference in the number of cases with a history of atopy, G1 75 (32.5%) vs G2 58 (36.2%), or already on inhaled steroids G1 24 (10.4%) vs G2 18 (7.8%).

Treatment with montelukast did not reduce overall admissions, G1 103 (45%) vs G2 65 (41%), nor did it reduce average length of stay (days) G1 1.52 vs G2 1.95. Further there was no significant difference in re-attendance rates to the ED within 7 days, G1 22 (9.95%) vs G2 21 (14.4%).

Conclusion

Treatment with montelukast had no significant impact on admission rates, length of stay or reattendance to hospital in children <5 yrs presenting with wheeze.

Existing departmental guidelines were poorly adhered to, with some children receiving treatment despite no prior history of wheeze whilst many with previous wheeze did not receive it. Instead, we observed a tendency towards treating those who had previously received the drug and those with signs of respiratory distress.

This study raises further questions regarding the use of montelukast in pre-school acute wheeze, and whilst limited as a retrospective study, it supports the doubts over its use as rescue therapy in these children.
SHOULD WE OFFER OPPORTUNISTIC VACCINATION IN THE PAEDIATRIC EMERGENCY DEPARTMENT?
Authors: Newell K , Rousseva C , Slade C , Isba R
Published: November 2015

Objectives & Background

Despite the importance of children being up-to-date with routine childhood immunisations, uptake rates remain sub-optimal. Guidance from NICE and the WHO state that every contact a child has with healthcare services be thought of as an opportunity to provide catch-up immunisation. Paediatric emergency departments (PED) therefore have the potential to increase local vaccination rates.

The overall aim of this work was to look at the viability of introducing opportunistic vaccination into the PED. The aim of these two audits was to look at potential barriers to such a programme.

Audit 1: is vaccination status recorded in the notes of children presenting to the PED at North Manchester General Hospital (NMGH)?

Audit 2: do PED staff currently deliver vaccinations in the department?

Methods

Audit 1: a retrospective audit of the notes of 500 children who presented to the PED before their third birthday. Basic demographic data were recorded along with what vaccination history appeared in their notes.

Audit 2: a retrospective audit of pharmacy orders for vaccines for the PED over a five and a half year period. These data were used as a proxy for how many vaccinations were administered in the PED the same time period.

Results

The audit of vaccination status demonstrated that only 28% of attendees had their vaccination status recorded, but 93% of these were up-to-date with their vaccinations to an age-appropriate level.

The audit of paediatric vaccinations demonstrated that across the 66 month period, 75 vaccinations were ordered.

This work suggests vaccination status is not well recorded in the PED. In the absence of access to centrally-held vaccination records, this may prevent introduction of a successful programme. Additionally, it appears that only a small number of vaccinations are currently given in the department, suggesting that there may not be sufficient existing vaccination expertise.

Conclusion

Whilst these findings do not support the introduction of opportunistic vaccination to provide catch-up for routine childhood immunisations, this approach deserves further exploration and future work could look at signposting children back to primary care, rather than offering the vaccination in the department. However, it may be possible to offer other, non-routine vaccines in the PED as a way to increase local vaccination rates e.g. by offering intranasal seasonal influenza vaccination to children attending the PED.