bluuebunny/crossref_metadata_2025 huggingface dataset:
14 Prediction of massive blood transfusion in battlefield trauma: development and validation of the military acute severe haemorrhage (MASH) score
Authors: Mclennan Jackie , Smith Jason , Mackway-jones Kevin
Published: November 2017

Background

The predominant cause of preventable death from trauma is bleeding. Many patients need resuscitation with massive blood transfusion (MBT). In some theatres of military operation there is limited blood product availability and walking donor panels can be required. This study aimed to produce a tool to predict the need for MBT using information available on patient arrival at the ED for patients sustaining battlefield trauma.

Methods

A retrospective database analysis was undertaken using the UK Joint Theatre Trauma Registry (JTTR) to provide derivation and validation datasets. Regression analysis of potential predictive factors was performed. MBT was defined either as receiving 6 or more units of red blood cells (RBCs) in 4 hours or 10 units of RBCs in 24 hours. Predictive factors were analysed through multi-logistic regression analysis to build predictive models; sensitivity and specificity of these models was assessed, and the best fit models were analysed in the validation dataset.

Results

The derivation dataset was made up of 1298 casualties with a massive blood transfusion rate of 21.2% (n=275). The validation dataset contained 1186; MBT rate 6.7% (n=79). The majority of patients were young, male and with penetrating injury. Univariate regression analyses showing the predictive value of the variables within the MASH score are shown in table 1. A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital interventions. The test characteristics for three cut off thresholds for the rule are shown in Table 2 alongside the sensitivity analysis. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of MBT, with an AUROC of 0.93 (95% CI:0.91 to 0.95).

Table 1

Univariate regression analysis of variables included in the MASH score in the derivation dataset which predict the requirement for 6 units of pRBCs in 4 hours or 10 units of pRBCs in 24 hours

Table 2

Performance of the MASH score in derivation and validation datasets showing test characteristics for three values of the MASH score with 95% confidence intervals with sensitivity analysis for a score of 3 in the validation dataset

Conclusions

This study has produced the first military scoring system that uses clinical observations, injuries sustained and pre-hospital interventions to predict the need for MBT and therefore the requirement for an emergency donor panel in resource-limited environments. The MASH score has higher sensitivity and specificity than previous military prediction tools, and has the advantage of only using information which is rapidly available in the resuscitation bay. This is of importance to civilian practitioners with increasing possibility of major terrorist attacks.
18 How do public attitudes to automated external defibrillators affect their use in out-of-hospital cardiac arrest?
Authors: Choi Hyun , Bosompra Nana , Updyke Mathew , Adebowale Adesina
Published: November 2017

Introduction

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

Methods

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

Institutional ethical approval was obtained.

Results

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

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

Conclusion

The level of knowledge of AEDs is low amongst the general public. Majority of the study population who knew about AEDs had some degree of resuscitation training. Further research is required to ascertain how to translate knowledge into optimal use of AEDs in practice.
19 Accuracy of biomarkers for venous thromboembolism in pregnancy: the diagnosis of pulmonary embolism in pregnancy (DiPEP) biomarker study
Authors: Goodacre Steve , Hunt Beverley , Parmar Kiran , Shephard Neil , Horspool Kimberley
Published: November 2017

Objective

To estimate the accuracy of biomarkers for venous thromboembolism (VTE) in pregnant and postpartum women with suspected pulmonary embolism (PE).

Design

Observational cohort study augmented with additional cases with VTE.

Setting

Emergency departments and maternity units at eleven prospectively recruiting sites.

Participants

Pregnant or postpartum women presenting with suspected PE or diagnosed DVT.

Interventions

Research nurses/midwives collected a blood sample from women with suspected PE or diagnosed DVT and data relating to diagnostic imaging, treatment and adverse outcomes. Blood samples were centrifuged, stored and then transported to Guy’s St Thomas Trust for analysis.

Main outcome measures

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

Results

Usable blood samples were taken from 18 women with diagnosed DVT and 310 women with suspected PE, of whom 18 had PE confirmed by imaging and 247 had PE ruled out after imaging and were included in the primary analysis. Mean biomarker levels only significantly differed between women with and without PE for Clauss Fibrinogen (p=0.007), ELISA D-Dimer (p=0.001), Innovance D-Dimer (p=0.004), Thrombin Generation Lag Time (p<0.001), Thrombin Generation Time to Peak (p=0.001) and Plasmin Antiplasmin (p=0.004). The AUC (95% CI) for each biomarker was APTT 0.669 (0.570 to 0.768), BNP 0.549 (0.453 to 0.645), C-Reactive Protein 0.542 (0.445 to 0.639), Clauss Fibrinogen 0.589 (0.476 to 0.701), ELISA D-Dimer 0.668 (0.561 to 0.776), Innovance D-Dimer 0.651 (0.545 to 0.758), MRproANP 0.524 (0.418 to 0.630), PF1 +2 00.562 (0.462 to 0.661), Plasmin-antiplasmin 0.639 (0.536 to 0.742), Prothombin Time 0.613 (0.508 to 0.718), Thrombin Generation Lag Time 0.702 (0.598 to 0.806), Thrombin Generation Endogenous Potential 0.559 (0.437 to 0.681), Thrombin Generation Peak 0.596 (0.478 to 0.715), Thrombin Generation Time to Peak 0.655 (0.541 to 0.769), Tissue Factor 0.531 (0.424 to 0.638) and Troponin 0.597 (0.499 to 0.695). ROC analysis showed that only thrombin generation lag time had any potential to rule out PE with sufficient sensitivity while achieving meaningful specificity, with sensitivity of 97% and specificity of 25% at the threshold that optimised sensitivity. Repeat analysis excluding women who had received anticoagulation was limited by the small number (n=4) who had PE.

Conclusion

Currently available biomarkers show little potential for aiding the diagnosis of suspected PE in pregnancy and postpartum.

Figure 1

Figure 2

Figure 3
22 Emergency department litigation and coroner’s inquests: a ten year analysis
Authors: Tilbury Nicholas , Tabner Andrew , Johnson Graham
Published: November 2017

Introduction

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

Method

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

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

Number of claims by year

Number of successful and unsuccessful claims by year

Number of settled claims

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

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

Report date

Age and gender of the deceased

Report summary

Results

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

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

Discussion

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

This analysis of litigation patterns and PFD reports provides an insight that enables further focus on the underlying causes, subsequent improvement in patient care and a reversal of current litigation trends.
23 Patient and staff perspectives on the reasons for increasing emergency department attendances
Authors: Ablard Suzanne , Rimmer Melanie , O’Keeffe Colin , Mason Suzanne
Published: November 2017

Background/objectives

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

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

Methods

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

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

Results

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

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

Conclusion

We found evidence of a rise in patients being referred to the ED by other healthcare services. This may be a reflection of the wider healthcare system under strain, thereby causing overspill into EDs. Future research is needed to design and test interventions that can lead to improvements in the system that are acceptable to patients, do not lead to increased demand, are cost-effective and lead to more sustainable working environments.
24 An audit into the number of patients suffering out-of-hospital cardiac arrest that are resuscitated despite a high likelihood of futility
Authors: Cokljat Mia , Clegg Gareth , Clarke Scott
Published: November 2017

Background

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

Methods

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

Results

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

Conclusions

Our results suggest that community DNACPR implementation in Edinburgh is suboptimal, with many patients resuscitated and transported to the ED with ongoing resuscitation despite a high likelihood of futility. It is unclear what is required to improve this situation. Possible avenues for improvement may be more anticipatory care planning in the community, better recording of the outcomes of key conversations with patients and carers, or more consistent implementation of these plans by Ambulance Service responders. We plan further work to establish how this system can be changed to serve patients and their families better.
26 Protocol for the upcoming study: patient input monitoring of pain in the emergency room: novel electronic log (PIMPERNEL): a randomised controlled trial of an electronic pain score display in adults in the emergency department
Authors: Thornton Hilary , Coats Timothy
Published: November 2017

Background

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

Equipment

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

Objectives

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

Inclusion criteria

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

Study procedure

We aim to recruit 200 patients (100 per arm) from the emergency department at Leicester Royal Infirmary. All patients will use the display. This is a parallel group, two arm superiority trial with a 1:1 allocation ratio. Patients will be randomised to have their pain score on display (intervention) or hidden (control). Blinding is not possible. The display beeps every 15 min to remind patients to enter their pain score. Treatment will not be constrained by study protocol and will depend on the judgment of the treating clinician. The study will continue for up to 6 hours to allow time for the first dose of analgesia to wear off. Data collection will cease when the patient leaves the department. Questionnaires will be given to participants and the staff nursing them.
27 The DiPEP (Diagnosis of PE in Pregnancy) study: can clinical assessment, d-dimer or chest x-ray be used to select pregnant or postpartum women with suspected PE for diagnostic imaging?
Authors: Goodacre Steve , Horspool Kimberley , Nelson-piercy Catherine , Knight Marian , Shephard Neil , Lecky Fiona , Thomas Steven , Hunt Beverley , Fuller Gordon
Published: November 2017

Objective

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

Design

Observational cohort study augmented with additional cases.

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

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

Conclusions

Clinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.
3 Derivation and internal validation of a clinical decision rule to guide whole body computed tomography scanning in trauma
Authors: Chatha Hridesh , Sammy Ian , Body Rick , Sattout Abdo , Hollingsworth John
Published: November 2017

Background

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

Methods

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

Results

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

Figure 1

Conclusion

This study derived a two stage CDR which was highly sensitive for identifying patients at high risk of multiregion injury. A prospective external validation study is now required to further refine and improve this model. This could provide a useful screening tool in the future.
30 Do nice guys finish last?
Authors: Turner Chris , Turner Jake
Published: November 2017

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

Methodology

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

Questions included

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

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

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

Conclusions

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

Figure 1

Average interruptions per hour by friendliness score
31 The quality improvement QIP – improving multidisciplinary staff engagement with quality improvement in the RVH emergency department
Authors: Bannon Olly , Greenwood Emma
Published: November 2017

In recent years the RVH Emergency Department (ED) had been under intense pressure and public scrutiny. This led to a demoralised workforce who had become disengaged with quality improvement (QI). QI projects had become an exercise in data collection with little focus on improving care for patients.

Two consultants undertook training in QI and then decided to develop a QI project aiming to empower staff and embed QI as daily practice. An ED QI steering group of interested multidisciplinary members was formed and devised an improvement plan to increase staff engagement with QI.

The steering group secured funding for a subscription to the Institute of Healthcare Improvement (IHI) online open school. This was made available to 50 staff and was used to increase knowledge of QI methodology. An aim of 250 open school modules completed by August 2017 was set. This total was surpassed in June 2017, amounting to over 330 hours of QI training undertaken in staff’s own time. To date 13 staff members have achieved IHI Certificates in Quality and Safety.

We designed a series of projects which were linked with the Trust Improvement plan. The QI teams are all multidisciplinary with medical and nursing staff from different grades involved in each as well as input from other professionals such as pharmacy, physio and clerical/admin staff.

Figure 1

Through the delivery of this project the ED team’s enthusiasm for QI has been reinvigorated. We have demonstrated improvements in clinical standards such as pain management where a project was undertaken, which has seen a 4 fold increase in the number of patient’s who sustain a fractured hip receiving the gold standard treatment of fascia iliaca nerve block.

We have shown improvements in communication with the ‘Unfinished Symphony’ project demonstrating significantly better ED/GP written handover correspondance and the ‘What’s in a name’ project decreasing inter-specialty conflict during the referral process. We have also increased efficiency with senior review for Ambulance patients and subsequent significant decrease in waiting times. A recent project targeting the waste associated with unnessecary triage blood tests is showing promising early results.

Figure 2

The ED improvement team have endeavoured to improve the environment for staff by developing a ‘Grrr to Great’ board, through which staff are empowered to highlight problems but are also tasked with developing solutions. We have also increased accessibility of QI data by producing a QI update board and displaying data openly and transparently in the department.

Figure 3
32 Do low-risk patients with non-cardiac chest pain prefer early discharge after rapid rule-out in the emergency department?
Authors: Hancock Isabelle , Carlton Edward
Published: November 2017

Background

There has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED). Previously, such patients would have been admitted to a hospital bed for observation and delayed biomarker testing. While the drive to implement rapid rule-out strategies comes from healthcare providers, there has been little assessment of patient perspectives on early discharge, in what is known to be a high-anxiety presentation. We aimed to explore patient perspectives on the acceptability of early discharge strategies.

Methods

This prospective quantitative survey was conducted on consecutive patients admitted from the ED to a short-stay ward for evaluation of suspected cardiac chest pain at a single centre in the UK. All patients were discharged within 36 hours with a diagnosis of low-risk chest pain. The written questionnaire was designed with closed answer questions with responses standardised along a 5-point Likert scale and was completed by patients upon discharge. Ethical approval was obtained.

Results

Of 739 patients requested to complete the survey, 278 (37.6%) responded. Mean age 56.6 years (SD 13.4), 263/278 (94.6%) White British, mean length of stay 15.5 hours (SD 6.6), 6/278 (2.2%) had a major adverse event (MACE) at 30 days. Responders were more likely to be female than non-responders (49.6% vs 37.5%, p=0.001), otherwise groups were matched in age, cardiac risk factors, length of stay and the presence of MACE (p>0.05 for all).

Table 1

Summary of patients’ responses from questionnaire

The majority of patients, 197/278 (70.8%) would have been satisfied or very satisfied with early discharge directly from the ED, with 36/278 (13.0%) expressing dissatisfaction with a proposed rapid rule-out strategy. However, 249/277 (89.9%) of responders were reassured by admission to the ward and 112/273 (41.0%) felt they could not have spent any less time in hospital. Through binary logistic regression we analysed potential predictors of dissatisfaction with early discharge, these were sex, age, severity and type of pain at presentation, previous ischaemic heart disease, family history and found none were significant.

Conclusions

Most patients would be satisfied with a rapid rule-out strategy, however, it should be acknowledged that patients receive reassurance from hospital admission and over 10% of patients would be dissatisfied with discharge direct from ED. Improved patient information and shared decision making is required when rapid discharge strategies are incorporated into practice.
33 Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest
Authors: Vopelius-Feldt Johannes von
Published: November 2017

Background

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

Methods

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

Results

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

Table 1

Conclusion

Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.
35 To pan-scan or not to pan-scan? Further analysis of the tarn database 2012–2017
Authors: Hunt Paul , Lecky Fiona , Bouamra Omar
Published: November 2017

Background

A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven.

We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s).

Methods

We analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases.

Results

15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1.

Table 1

Patients characteristics

Propensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2.

Table 2

Modelling morality using pan-scan as exposure factor

The results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS).

Conclusion

The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.
37 Routine testing of salicylate levels in overdose patients: still needed?
Authors: Hardy Elaine , Toro Clare , Dorrian Susan , Salanke Umesh
Published: November 2017

Introduction and aims

Overdose is a common presentation in Emergency Departments (EDs) across the UK. Salicylate poisoning is potentially fatal; however it is becoming increasingly uncommon in the UK. This may be due to restriction of pack sizes in over the counter medicines as well as the use of aspirin as an analgesic being superseded by other NSAIDs, particularly ibuprofen.

In conjunction with clinical features of salicylate toxicity, measurement of plasma salicylate concentration can help guide management. Many EDs routinely test for salicylate levels in all cases of overdose, and yet this may not be necessary as recommended by the NPIS.

This study aims to assess the cost implication of over testing for salicylate in overdose patients, as well as the prevalence of salicylate poisoning in three EDs in the West Midlands.

Method

A multicentre retrospective case note study was undertaken from January 2016 to March 2017. Data were collected from 3 EDs in the West Midlands. Cases of overdose where salicylate levels were requested were identified in conjunction with biochemistry departments, and information gathered regarding age, gender, nature of overdose, patient weight, GCS, clinical features of salicylate toxicity and plasma salicylate concentration.

Results

Across the three centres, 4296 requests were made for salicylate levels during the study period. Of those samples, just 115 detected any salicylate at all (2.7%). The majority of these samples had levels just over limit of detection.

This is in keeping with the previous observation that salicylate poisoning is uncommon.

Of the 4296 samples sent, 3651 were not indicated, i.e., no clinical features, patient alert, and denied aspirin overdose.

With the cost of plasma salicylate concentration analysis being £4.58 (average over the 3 sites) there is a potential cost saving of £16 721 per year.

Conclusions

Salicylate poisoning appears to be uncommon among patients presenting with overdose.

Results show that it is likely that EDs are over testing for salicylate levels.

In accordance with NPIS advice, there is no need to measure salicylate levels in conscious overdose patients who have no features of toxicity and deny salicylate ingestion.

This may have cost implications, allowing departments to save money by reducing the amount of routine salicylate testing overall.
39 Violence intervention and prevention in emergency rooms: the viper study
Authors: Price James , Martin Michael , Dean Jon , Ahmed Haroon , Waite Matthew , Boyle Adrian
Published: November 2017

Background

Nearly half a million people are killed each year as a consequence of intentional injury and many more seriously injured. Information sharing by Emergency Departments with local government for crime prevention purposes has previously been described as an effective, cost effective, low cost and low risk intervention for tackling community violence. The UK Department of Health and the Home Office support this process known as the Information Sharing to Tackle Violence (ISTV) program. In 2007, we implemented ISTV and have witnessed a substantial reduction in assault related attendances. We aimed to examine the epidemiology of our assault victims over the introduction period. We hypothesiseda priorithat there would be reductions in the proportions of patients who attended at the weekend and late at night, reductions in the proportions of young adult males, and reductions in the more seriously injured patients.

Methods

We extracted all the cases of assault from our patient administration system between the 1 st of January 2005 and the 31 st of December 2014 and analysed the data using Poisson regression. To estimate the trend over the 10 year period, we used indicator variables for each year (other than 2005 which was treated as the reference category) to allow for non-linearity. Deviance tests of the models were used to assess whether the inclusion of the interaction terms improved model fit. When there was evidence of statistically significant interactions, we re-ran the model looking at the rate of change over time separately for each strata of the effect modifier.

Results

Over the study period, the rate of emergency department presentations following an assault decreased up until 2014, at which point it was 37% lower (IRR=0.63; 95% CI:0.57 to 0.69) than in 2005. There were greater reductions for presentations on weekends (IRR=0.57; 95% CI:0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI:0.62 to 0.83); presentations with no hospital follow-up (IRR=0.51; 95% CI:0.45 to 0.56) versus those leading to either an inpatient (IRR=1.05; 95% CI:0.84 to 1.31) or outpatient (IRR=1.23; 95% CI:0.93 to 1.64) follow-up over the 10 year period.

Conclusions

The ISTV program in this single ED has been associated with substantial reductions in violence related presentations. This effect is most marked in presentations at the weekend, younger patients and in those who appear to be least seriously injured.
4 The risk of deterioration in CT identified mild traumatic brain injury: a systematic review and meta-analysis
Authors: Marincowitz Carl , Lecky Fiona , Townend William , Borakati Aditya , Sheldon Trevor
Published: November 2017

Background

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

Objective

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

Figure 1

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

Methods

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

Results

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

Figure 2

Meta-regression of study factors predictive of neurosurgery

Conclusion

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

Figure 3

PRISMA flow-diagram showing selection of studies for inclusion in the systematic review
40 ED crowding: the acceptability of dysfunction
Authors: Kavanagh Karl , Shields Darragh , Staunton Paul
Published: November 2017

Background

Crowding in the Emergency Department is internationally recognised as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of crowding, including increased length of stay, mortality and cost per admission. Crowding is typically a manifestation of a hospital at full capacity and its main contributor is the practice of boarding patients in the ED. Therefore, a functioning flow system is advised to ease the burden. Different predictive tools/algorithms assess the degree of crowding. The National Emergency Department Overcrowding Scale (NEDOCS) is used effectively in other countries but has not been validated in Ireland.

Aims

To assess crowding in a major Irish teaching hospital over a three week period at regular time periods using the NEDOCS.

To look at the time from decision to admit to ward bed availability in order to improve flow through the department.

Staffs perception of crowding was assessed at a random single time point.

Methods

Application of the NEDOCS score in the Emergency Department along with the use of internal Patient Administration System (PAS) to track patient movement through the ED.

Results

During the three week period, the NEDOCS score was frequently at level 6 (dangerously overcrowded) or level 5 (severely overcrowded) (see figure 1). Emergency patient registrations peaked between 1000 hours to 1300 hours whereas the peak admission time to wards was between 1900 hours and 2300 hours. At a random time point, Universal staff perception of crowding in the department was perceived as ‘It’s a nice day’. However the NEDOCS level was 4 (overcrowded) suggesting significant crowding.

Figure 1Figure 2

Average reception activity per 24 hour

Conclusion

Our Hospital is operating at a consistent level of crowding that can negatively impact on patients. Access to inpatient beds is available late in the day, creating a time lag between decision to admit and transfer to ward. Staff perception did not correlate with NEDOCs score, possibly reflecting a conditioning and acceptance of staff to crowding.

Discussion

We plan to validate the NEDOCS score in an Irish Emergency Department. Crowding is a significant issue in the Irish Healthcare setting. The ‘40% of inpatient beds by 11 am’ needs to be adopted by our hospital. Our study suggests that our emergency staff accept the dysfunctional as the norm.