bluuebunny/crossref_metadata_2025 huggingface dataset:
41 Simultaneous trauma patients in emergency department’s: a difference in mortality?
Authors: Morrow Laura , Nutbeam Tim
Published: November 2017

Background

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

Methods

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

Results

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

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

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

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

Conclusion

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

Table 1

Further work planned will understand the impact of multiple trauma patients on length of stay and time to CT/operating theatre.
42 Assessing factors affecting the quality of chest compressions during training for laypersons using a novel CPRCARD
Authors: Sim Zariel , White Alexander Elgin , Wah Win , Ready Steven MJ , Mohd Jalil Nurul Asyikin , Ng Han Xian , Ong Marcus EH
Published: November 2017

Objective

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

Design and methods

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

Results

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

Conclusions

Overall, at least 1 parameter of chest compression quality decreased with age, and was better in males than females. A possible application of these results is to have differences in training methods for different ages and sexes, targeting parameters that they are weaker at.
44 Quantifying the 5 year mortality of frequent attenders to the emergency department
Authors: Davison Alexander , Boyle Adrian , Hayhurst Catherine
Published: November 2017

Introduction

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

Methods

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

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

Initial results

(pending full statistical analysis)

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

Conclusion

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

The crucial finding is that the risk of death for adult FAs between the age of 16–65 is much higher than would be expected of the normal population. This indicates a need to treat this population with increased care.
45 Patient evaluation of trauma service
Authors: Jagdev Balraj , Gardiner Hannah , Turner Chris
Published: November 2017

Patient Experience of the Trauma System (PETS)

Trauma care is highly organised, time critical medicine. Changes to patient management in trauma care are often the result of Random Control Trials, and expert opinion following rigorous evaluation of the evidence. Highly efficient, injury focused care is required to achieve the best outcomes for patients. One area that has not been researched so thoroughly however, is the patient experience of trauma care. As evidence already suggests that patients with high stress levels have poorer outcomes, we wanted to investigate the patient perception of the trauma system. We were particularly interested to find out if there were any areas where patient anxieties could be reduced or eliminated.

Methodology

A ten-person qualitative study was initially conducted to test for feasibility and reproducibility. The methodology involved semi-structured interviews investigating outcome measures such as the patient’s perception of being looked after, biggest concerns and understanding of care, among others. Interviews were undertaken by a medical student and a Foundation Year 2 doctor (at the end of the Emergency Medicine block, post sign-off) trained in the methodology.

The initial study was carried out over one month in early 2017 and involved adult patients (>18 years) admitted via the trauma care pathway who were Glasgow Coma Score 15/15. Interviews took place within 48 hours of admission in the Emergency Department (prior to transfer), the observation ward or the extended care trauma unit. Barriers to patient interviews included: severity of injuries; patient refusal; language proficiency and patient recollection (some had no recollection of being in resus). Despite this we managed an initial sample of 10 patients, with rich data.

Following on from the pilot study we have made some amendments to our questions and have conducted a further set of 20 interviews.

Conclusions

A significant proportion of patients have concerns during trauma care that they feel unable to voice. This has the potential to increase their stress levels and have an adverse impact on their recovery. The concerns are varied and not always predictable, often unrelated to the injury. Thus we feel there may be patient benefit from the use of a single open question towards the end of the primary survey. We suggest AMPLE-AE for ‘is there Anything Else you would like to tell me or ask about?’
46 Testing of the ‘always events’ approach to improve the patient experience in the emergency department
Authors: Kay Cameron , Lowe David
Published: November 2017

Aims

This project aimed to identify issues patients would like to see improved when interacting with the Minor Injuries Unit (MIU) and as a result generate measurable and feasible Always Events (AEs) based on patient feedback that can be implemented via a Quality Improvement (QI) process. We then looked to assess and improve on the delivery of the agreed AEs to enhance MIU patient experience.

Methods

AEs were identified by using a short semi-structured survey questionnaire with a free text response section from 45 patients. Patients were asked what should always happen in the ED. Iterative thematic analysis identified information provision and explaining how the department worked as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented to address this issue. Improvement was assessed via convenience sampling of patient questionnaires using a five-point bipolar Likert scale and free text responses which were compared to a set of baseline results via run charts to examine impact of each intervention. A total of 300 patients completed questionnaires throughout the baseline and intervention periods.

Results

Baseline results stood at 80% for patient satisfaction regarding information provision, rising to 88% by the end of the poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions stood at 83% in the baseline sample before rising to 86% throughout the poster and video intervention. Composite survey results rose from a baseline level of 82.2% to 86.3% for the poster intervention and 88.8% by the end of the video intervention stage. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period.

Figure 1Figure 2

Discussion

Implementing the AE approach in the MIU has had a positive effect on patient experience. The poster intervention had the greatest impact on enhancing patient understanding. Our study indicated that direct information provision from staff was sufficient for patients and improvements in responses were due to the project interventions. Next steps should be to further implement the video in the department via inclusion on the patient Wi-Fi homepage and waiting room television to maximise the impact of the video. The patient–staff co-design nature of this study shows the AE methods strength in improving patient-centred care. In summary, this project emphasises that the AE method is an effective, valid and beneficial form of Quality Improvement to be used within EDs which has the potential for widespread future use.
47 Systematic review and meta-analysis of analgesic efficacy and safety profile of single injection fascia iliaca compartment blocks in the acute pre-operative pain management of hip fractures
Authors: Fadhlillah Fiqry , Chan David
Published: November 2017

Background

It is hypothesised that a single injection fascia iliaca compartment block (FICB) administered in the pre-operative setting provides better analgesic control for traumatic hip fractures and is not associated with major adverse effects. Systemic analgesics, whilst effective, could lead to cardiovascular, respiratory and cognitive impairment. As a consequence, undertreatment of acute pain remains prevalent in adult patients with hip fractures, with a consistent decline seen in analgesic administration with age.

Objectives

Determine the analgesic efficacy and safety profile of single injection FICB performed in the pre-operative period for acute pain management in adult patients with traumatic hip fractures compared to other forms of analgesia.

Methods

MEDLINE, EMBASE, Cochrane and CINAHL were independently searched to identify randomised controlled trials (RCTs) in English. Patients aged >18 years old who have suffered an isolated traumatic hip fracture (proximal femoral fracture) and received single injection FICB pre-operatively were included. No date restriction was applied and key journals and articles were scrutinised to include studies not identified by the primary search.

Results

Out of 3757 citations, eight RCTs were included in the final quantitative analysis, comprising of 645 participants. Acute pain was significantly reduced in FICB during positioning and movement, standardised mean difference (SMD)=−1.82 (95% CI:−2.26 to −1.38, p<0.00001) but was variable at rest (p=0.20). There was a reduced incidence of analgesia breakthrough (n=57 versus n=73), drowsiness/sedation (n=1 versus n=22), desaturation (n=0 versus n=4) and nausea and vomiting (n=3 versus n=7) in the FICB arm. There were similar numbers of patients across both arms that reported localised bruising (n=3). Only one study was at low risk of bias.

Figure 1Figure 2

Conclusions

FICB is superior in controlling acute pre-operative pain in adult patients with traumatic hip fractures. The benefit is more evident during positioning and mobilisation of the limb. FICB has a better safety profile and reduces dependency on systemic analgesia.
48 Calpol: are we overdosing on blood tests?
Authors: Patel Brijesh
Published: November 2017

Background

In February 2012, the Commission on Human Medicines recommended lowering the paracetamol toxicity treatment threshold for all patients. Children between one month and six years of age are physiologically distinct and metabolise paracetamol differently, making them less prone to toxicity. Furthermore, overdose in early childhood is almost exclusively accidental, as opposed to predominately deliberate self harm seen in adults and adolescents. As a result, the use of the new 75 mg/kg ingestion threshold for young children would appear to be of unproven benefit, and is substantially lower than the threshold used in other countries.

Aim

To establish the sensitivity and negative predictive value of using a 150 mg/kg ingestion threshold to identify hepatotoxicity in children one month to six year old group with paracetamol overdoses.

Method

Retrospective case review. Potential cases were identified by filtering an electronic Patient Management System for a discharge diagnosis of ‘accidental ingestions and poisonings’ over the period 1 st January 2012 to 19th October 2016 (57 months). ED documentation was reviewed to identify cases of paracetamol ingestions by children under the age of 6 years. Those with intentional harm, known staggered ingestions over 1 hour or under one month age (corrected for gestation) were excluded.

Clinical notes and laboratory data were reviewed and, data parameters collated using a standardised proforma. Ingested doses were estimated, where possible, by subtraction methods. In some cases, the ingestion time was revised according to the time that the child was previously seen prior to the ingestion. A composite outcome for hepatotoxicity was used consisting firstly of the current UK standard treatment threshold (100 mg/L line on paracetamol toxicity nomogram) together with any evidence of biochemical hepatoxicity or clinical features of potential hepatotoxicity at any subsequent ED attendances over the next 7 days.

Results

The final cohort consisted of 165 individual patient ingestions. A 150 mg/kg ingestion threshold had a sensitivity of 100.0% (95% CI:47.5 to 100.0) for hepatotoxicity, with a negative predictive value of 100% (95% CI:97.5 to 100.0).

Conclusion

This retrospective study supports the hypothesis that accidental paracetamol ingestions less than 150 mg/kg, in children one month to six years of age, can be safely managed without investigation or treatment, in accordance with other international guidance. The use of 150 mg/kg threshold would reduce testing in over a third of attendances in our cohort. Study limitations include retrospective bias and the predominate use of serum paracetamol levels to determine toxicity.
49 Paediatric traumatic cardiac arrest – the development of a treatment algorithm
Authors: Vassallo James , Nutbeam Tim , Rickard Annette , Lyttle Mark , Smith Jason
Published: November 2017

Introduction

Paediatric Traumatic Cardiac Arrest (TCA) is a high acuity, low frequency event with fewer than 15 cases reported per year to the Trauma Audit Research Network (TARN). Traditionally survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable to that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation.

The aim of this study was, by a process of consensus, to develop a national, standardised algorithm for the management of paediatric TCA.

Methods

A modified consensus development meeting was held. Statements discussed in the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three round online Delphi study. Those participants completing the first round of the Delphi study were invited to attend.

19 statements relating to the diagnosis, management and futility of paediatric TCA were discussed in small groups. After five minutes the key points from the small groups were presented to the whole audience. Subsequently, using electronic voting devices, each participant anonymously recorded their agreement with the statement using ‘yes’, ‘no’ or ‘don’t know’. In keeping with our Delphi study, consensus was seta prioriat 70%. Statements reaching consensus were included in the proposed algorithm.

Results

41 participants attended the consensus development meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma. The proposed algorithm for the management of paediatric TCA is shown as Figures 1 and 2 for blunt and penetrating trauma respectively.

Figure 1Figure 2

Conclusion

In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first algorithm specific to the paediatric population.
51 Paediatric emergency clinicians are rarely exposed to non-airway critical procedures: a predict/PERN study
Authors: Garrahan Juan P , Lyttle Mark , Oakley Ed , Dalziel Stuart , Nguyen Lucia , Rao Arjun , Mintegi Santiago , Babl Franz
Published: November 2017

Background

Recent studies suggest that approximately one per thousand paediatric ED attendances may require some sort of critical procedure, with intubation being by far the most common. It is unknown how often critical non-airway procedures such as chest decompression, CPR, ED thoracotomy, defibrillation, pacing, and advanced vascular access techniques are performed by paediatric emergency clinicians.

Objective

To determine the recent performance or supervision, and confidence for various paediatric critical non-airway procedures by senior paediatric emergency clinicians.

Design/methods

Web based survey of senior paediatric emergency clinicians regarding performance, supervision, and confidence relating to critical non-airway procedures in children aged 0–18 years. The survey was distributed through Paediatric Emergency Research Networks (PERN) in the UK and Ireland, USA, Canada, Europe, South America, Australia and New Zealand.

Results

1602 clinicians responded to the survey, with an overall response rate of 65%. 1508 (94%) respondents reported their most recent non-airway procedural experience. In the last 12 months, 979 (64%) had personally inserted an intraosseous line, 283 (19%) a central venous line, and 265 (18%) an arterial line. In the same time period, 962 (64%) had performed CPR, 190 (13%) had performed needle thoracostomy, 245 (16%) had performed tube thoracostomy, 380 (25%) had performed DC cardioversion or defibrillation, and 57 (4%) had performed transcutaneous pacing. 18 (1%) had performed pericardiocentesis, 19 (1%) a venous cutdown, and 21 (1%) ED thoracotomy. More than 70% of respondents had never supervised or performed pacing, pericardiocentesis, venous cutdown or ED thoracotomy. 332 (22%) and 348 (23%) had never performed or supervised insertion of a central venous line or arterial line respectively.

Procedural confidence for intraosseous lines and CPR was high, while confidence increased with increasing patient age for central venous access and arterial lines. ED thoracotomy, pericardiocentesis and venous cutdown had the lowest frequency of respondents reporting confidence in performing the procedure.

Conclusions

More than half of the paediatric emergency clinicians surveyed had performed CPR and inserted an intraosseous needle within the last 12 months. Performance of other non-airway critical procedures was less common, and associated with less procedural confidence.
52 Loop-mediated isothermal amplification PCR (LAMP) for the rapid identification of invasive meningococcal disease in the emergency department
Authors: Waterfield Thomas , Patenall Bethany , McKenna James , Fairley Derek
Published: November 2017

Background

Despite successful vaccination programmes meningococcal disease (MD) remains the leading infectious cause of septicaemia and death in children in the UK and Ireland.1,2The early diagnosis of MD significantly improves outcomes with reduced morbidity and mortality.1,2The early stages of MD are often indistinguishable from a simple viral illness making an early positive diagnosis of MD difficult.1Hibergene have developed a commercially available bedside Loop-mediated isothermal AMPlification PCR (LAMP-MD) test that is a highly sensitive 0.89 (95%CI 0.72–0.96) and specific 1.0 (95%CI 0.97–1.0) for identifying children with invasive MD (4) (figure 1).

Figure 1

Aims

The aims of this RCEM funded study were:

Assess the ease of use and suitability for the ED

Determine the time taken to perform the test

Independently verify LAMP-MD performance against TaqMan quantitative PCR.

Method

The LAMP-MD was assessed for practicality and ease of use within the ED including an assessment of training needs, footprint and health and safety requirements.

For verification of the Hibergene LAMP-MD analyser and assay we used dry nasopharyngeal swabs sent for viral screening. Additional verification was undertaken using N. meningitidis genomic DNA spiked over a range of concentrations. This included serotypes A, B, C, W, X and Y and a dilution series to determine the limit of detection. All samples were then analysed using real time TaqMan qPCR.

Results

The LAMP-MD analyser was easy to use and could be accommodated in the ED

The mean time for detection of Meningococcal DNA was 14.01 min

Detection of meningococcal serogroups A, B, C, W, X and Z was confirmed

The detection limit for dry nasopharyngeal swabs was below 2 genomic copies per µl

No non-specific amplification was observed in 17 randomly selected negative clinical swabs

The LAMP-MD assay was 100% sensitive and specific relative to real-time TaqMAN PCR.

Conclusion

LAMP-MD is a practical, rapid point of care test that can reliably detect all Meningococcal serotypes in less than 15 min.

Funding has been secured to perform a PERUKI supported study to investigate the potential for LAMP-MD in the diagnosis of meningococcal disease in children.

References

Meningitis Research Foundation.Meningococcal Meningitis and Septicaemia Guidance Notes2014.

Ó Maoldomhnaigh, et al.Invasive meningococcal diseasein children in Ireland. PMID: 27566800.

NICE.Management of petechial rash.

Bourke TW, et al.Diagnostic accuracy of loop-mediated isothermal amplification as a near-patient test for meningococcal diseasein children. PMID: 25728843.
53 Piloting patch – providing assessment and treatment for children at home – and piecing together what works
Authors: Ward Caroline , Knight Katie , Ballard Mary-Rose , Keogh Georgina , Samuel Miriam , Buttle Sara , Robb Claire , Cleugh Francesca
Published: November 2017

Aims

PATCH is a pilot acute community children’s nurse led service delivering assessment and treatment for children at home who are moderately unwell and might otherwise be admitted to hospital or attend Paediatric Emergency Department (PED). Children are referred by PED or GP and followed up via telephone support and home visits depending on clinical need for duration of acute illness.

Methods

Pilot year funded by Imperial Charity. Using evaluation to build business case for sustained commissioned service.

Phase 1 Sept 2016– May 2017:reduced short stay admissions and re-attendances to PED for common mild-moderate respiratory conditions e.g., viral wheeze, bronchiolitis.

Phase 2from May 2017:piloting direct GP referrals to PATCH team to evaluate impact in reducing attendances to PED for children needing further assessment or support beyond GP consultation, and enabling families to manage common acute conditions at home.

Using QI methodology, Model for Improvement we developed a driver diagram and used real-time PDSA cycles to capture our learning and inform small iterative changes of service development. Process mapping and world cafe style events were held with local community nurses, health visitor leads, GPs and commissioners to co-design referral pathways and explore more widely how PATCH fits into the whole urgent care system.

Figure 1

Parental feedback evaluated via semi structured interviews.

Results

Activity – Appendix 1

Phase 1 – Concentrated on respiratory conditions from PED.

Total 188 referrals in first 7 months. Bronchiolitis 45%; viral wheeze 37.5%; asthma 7%; lower respiratory tract infections 5.4%.

Figure 2

50% of patients received home visits and telephone consultations; 50% only telephone support.

Successes: Cost effective – Appendix 2

73 acute admissions avoided, costing c£400 per/night

97 PED re-attendances prevented at £117 per attendance.

Projected cost avoidance within acute care provider £3 27 640 pa.

Estimated cost of service £2 84 000 pa.

Positive feedback and reported health seeking behaviour change – Appendix 3

Challenges

Information governance, cross organisational working, complex commissioning arrangements.

Figure 3

Discussion

Within first 7 months PATCH has had a significant impact on avoiding admissions and re-attendances, thus improving flow and performance in PED. The projected financial impact is that it is cost effective.

We are using this data to pursue a business case internally and with local CCGs. We are optimistic of succeeding and using phase 2 to build on partnerships garnered across the whole system to expand PATCH’s impact further by reducing PED attendances and continuing to improve our local urgent care pathway for children.
56 Manipulation and reduction of paediatric forearm fractures using Es-ketamine in a paediatric emergency department – a 5 year study
Authors: Mulvaney Shirley
Published: November 2017

Background

Forearm fractures are the most common paediatric injury presenting to A+E.1,2Literature supports safe and effective treatment of these injuries in A+E using a variety of sedation methods, including ketamine.3,4The Paediatric Orthopaedic Trauma Snapshot (POTS) study showed that only 35% of A+Es nationally allow manipulation of these injuries in the department.

Methods

A retrospective analysis was undertaken of all patients presenting with fractures of the forearm between January 2012 to December 2016 who were treated with reduction and manipulation in the Alder Hey A+E department using Es-ketamine. Pre and post manipulation radiographs were reviewed, and fracture angulation measured pre and post reduction.

Results

A total of 151 patients were included with an average age of 8.5 years. 3 Salter Harris Type I, 16 Salter Harris Type II, 54 metaphyseal fractures, 44 distal third diaphyseal, 31 middle third diaphyseal and 3 proximal third diaphyseal were noted. 3 patients were lost to follow up after initial post reduction films. 11 patients required operative intervention following initial reduction. At one week follow up a further 5 patients were deemed to be of an unacceptable position requiring definitive operative management. No fractures slipped beyond 1 st week post procedure. A successful reduction, with improvement in lateral angulation, was achieved in 90% (133/148) of patients. The average pre-reduction lateral angulation was 23.7 degrees, post reduction was 4.6 and at final review was 0.3 degrees. At final follow up average 32 days all patients had clinical and radiological union.

Discussion

Es-Ketamine has been established as a safe method of sedation in paediatrics. Es-Ketamine allows same day discharge thus improving patient journey and leading to about £63 000 savings annually.

Conclusions

With adequate and appropriate training, the majority of simple radius and ulna fractures can be reduced and definitively treated safely and effectively using Es-ketamine in the emergency department. This technique has significant benefits in terms of resource management and finance whilst maintaining optimum patient care.
57 Support for suddenly bereaved parents in the emergency unit
Authors: Jones Emily , Simpson Steffan
Published: November 2017

The Paediatric Emergency Unit at the University Hospital of Wales provides care for over 33 000 children per year. There was no provision in place to support suddenly bereaved families. Staff felt that we could improve the services provided to families who’s children sadly died in the unit.

The aim was to provide immediate support for the suddenly bereaved families by working in partnership with local Charity 2 Wish Upon a Star. Together we created a Standard Operating Procedure (SOP) that consisted of a checklist and pathway allowing us to refer relatives for immediate physical and emotional support. The pilot ran for 12 months offering support and counselling tailored to each individual family.

The bereaving process begins in the emergency department. When a child had died families were given the to Wish Upon a Star memory boxes which contained physical support including two cuddly elephants, one to follow the patient and one for the parent/carer to keep and hand and foot print kits. As well as written booklets giving practical information on the next steps such as post mortems and funerals- these often very difficult questions to ask and answer. And about the charity itself. Once consent was gained by the staff, the families details were shared with the immediate support worker at the charity who would contact them within 24 hours.

The initial 12 months trial had 18 paediatric deaths, 17 of which took up the support offered to them. The informal feedback we gained was positive from both staff and families. Our relationship with the charity has enabled us to feedback to the individual nurse involved, thus improving staff well being.

Due to the success of this pathway it has been extended to include young adults up to the age of 25 years. The model has also been rolled out across critical care in UHW and is now being used in all emergency department in Wales.

This innovative partnership offers immediate support to bereaved families across Wales which has improved care and services provided by the University Health Board.
6 Prognostic value of the glasgow admission prediction score: hospital length of stay, mortality and hospital readmission
Authors: Jones Dominic , Cameron Allan , Mason Suzanne , O’Keeffe Colin , Lowe David
Published: November 2017

Introduction

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

Figure 1

Aim

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

Methods

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

Results

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

Figure 2

Discussion

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

Figure 3

References

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

Cameron A, et al. A simple tool to predict admission at the time of triage. Emergency Medicine Journal2014.
7 Mass casualty incidents: a review of triage severity planning assumptions
Authors: Hunt Paul
Published: November 2017

Background

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

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

Methods

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

Results

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

Conclusions

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

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

Table 1Table 2
8 Different approaches needed to manage ED demand among different age-groups
Authors: Rimmer Melanie , Ablard Suzanne , O’Keeffe Colin , Mason Suzanne
Published: November 2017

Background/objectives

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

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

Methods

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

Results

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

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

Conclusion

ED staff attribute distinctly different patterns of ED attendance to patients of different age groups, including reasons for attending ED, the route to the ED, and the rate of non-urgent attendance. Given this variation, proposed demand management interventions are likely to impact differently on different age groups, and one solution is unlikely to be optimal for all ages. Therefore a number of different approaches will be needed to manage ED demand among different age groups.
9 Closed chest compressions reduce survival in a model of haemorrhage-induced traumatic cardiac arrest
Authors: Watts Sarah , Smith Jason , Gwyther Robert , Kirkman Emrys
Published: November 2017

Background

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

Methods

The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 using 39 terminally anesthetised Large White pigs (35 kg, 29–40 kg) instrumented for invasive physiological monitoring. Following instrumentation and baseline measurements, animals underwent tissue injury (captive bolt to the right thigh) and controlled haemorrhage (30% blood volume). Mean arterial blood pressure (MAP) was maintained at 45 mmHg for 60 min, followed by a further controlled haemorrhage to a MAP of 20 mmHg. As arterial blood and pulse pressures spontaneously deteriorated further over a 5 min period, the randomised resuscitation protocol was initiated as follows: CCC (n=6); IV 0.9% saline (Sal n=8); IV autologous whole blood (WB n=8); IV saline +chest compressions (Sal +CCC n=9); and IV whole blood +chest compressions (WB +CCC n=8). 3×10 ml/kg fluid boluses were administered using the Belmont Rapid Infuser (200 ml/min). CCC were performed using the LUCAS II Chest Compression System.

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

Figure 1

Results

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

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

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

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

Conclusions

CCC were associated with increased mortality compared to intravenous fluid resuscitation. Resuscitation with whole blood demonstrated the greatest physiological benefit as demonstrated by highest numbers of animals achieving ROSC.
Neighbourhood characteristics and health outcomes: evaluating the association between socioeconomic status, tobacco store density and health outcomes in Baltimore City
Authors: Galiatsatos Panagis , Kineza Cynthia , Hwang Seungyoun , Pietri Juliana , Brigham Emily , Putcha Nirupama , Rand Cynthia S , McCormack Meredith , Hansel Nadia N
Published: November 2017

Introduction

Several studies suggest that the health of an individual is influenced by the socioeconomic status (SES) of the community in which he or she lives. This analysis seeks to understand the relationship between SES, tobacco store density and health outcomes at the neighbourhood level in a large urban community.

Methods

Data from the 55 neighbourhoods of Baltimore City were reviewed and parametric tests compared demographics and health outcomes for low-income and high-income neighbourhoods, defined by the 50th percentile in median household income. Summary statistics are expressed as median. Tobacco store density was evaluated as both an outcome and a predictor. Association between tobacco store densities and health outcomes was determined using Moran’s I and spatial regression analyses to account for autocorrelation.

Results

Compared with higher-income neighbourhoods, lower-income neighbourhoods had higher tobacco store densities (30.5 vs 16.5 stores per 10 000 persons, P=0.01), lower life expectancy (68.5 vs 74.9 years, P<0.001) and higher age-adjusted mortality (130.8 vs 102.1 deaths per 10 000 persons, P<0.001), even when controlling for other store densities, median household income, race, education status and age of residents.

Conclusion

In Baltimore City, median household income is inversely associated with tobacco store density, indicating poorer neighbourhoods in Baltimore City have greater accessibility to tobacco. Additionally, tobacco store density was linked to lower life expectancy, which underscores the necessity for interventions to reduce tobacco store densities.
Capacity Procurement in Logistics Service Supply Chain with Demand Updating and Rational Expectation Behavior
Authors: Liu Weihua , Zhu Donglei , Wang Yijia
Published: November 2017

This paper discusses the applicable conditions of two capacity procurement sub-strategies with two ordering opportunities, namely, sub-strategy I in which only increasing purchase quantity is allowed during the second ordering opportunity, and sub-strategy II in which either increasing or reducing order quantities is possible when the second order is placed. Our research is in the context of a logistics service supply chain (LSSC) consisted of a logistics service integrator (LSI) and a functional logistics service provider (FLSP). LSI purchases first a service capacity from FLSP long before demand is realized and then adjusts this ordering quantity based on demand updating. We developed the profit models for LSI and FLSP which also include the constraints of rational expectations. Based on the assumption of Bayesian updating, this paper investigates the conditions for sub-strategy II outperforming sub-strategy I. The main results are verified through numerical analysis. Counter-intuitively, sub-strategy II is not necessarily always better than sub-strategy I. When using sub-strategy II, LSI needs to purchase more service the first time of placing orders, but the expected profits increase for both LSI and FLSP only with certain conditions, which have been derived as propositions in this paper.
Einstein metrics and Einstein–Randers metrics on a class of homogeneous manifolds
Authors: chen Chao , chen Zhiqi , Hu Yuwang
Published: November 2017

In this paper, we give [Formula: see text]-invariant Einstein metrics on a class of homogeneous manifolds [Formula: see text], and then prove that every homogeneous manifold [Formula: see text] admits at least three families of [Formula: see text]-invariant non-Riemannian Einstein–Randers metrics.