bluuebunny/crossref_metadata_2025 huggingface dataset:
Association of severe hypoglycemia with depressive symptoms in patients with type 2 diabetes: the Fukuoka Diabetes Registry
Authors: Kikuchi Yohei , Iwase Masanori , Fujii Hiroki , Ohkuma Toshiaki , Kaizu Shinako , Ide Hitoshi , Jodai Tamaki , Idewaki Yasuhiro , Nakamura Udai , Kitazono Takanari
Published: May 2015

Objective

Although many studies have investigated the clinical characteristics of patients with diabetes with depression in Western populations, there is a lack of information regarding other ethnicities. We studied the association between clinical characteristics and depressive symptoms in Japanese patients with type 2 diabetes.

Methods

A total of 4218 Japanese patients with type 2 diabetes who were not taking antidepressants were divided into four groups according to the Center for Epidemiologic Studies Depression Scale (CES-D) score. The relationship between the severity of depressive symptoms and clinical parameters was examined cross-sectionally.

Results

After multivariate adjustments, the severity of depressive symptoms was significantly associated with body mass index, leisure-time physical activity, current smoking, sleep duration, sucrose intake, skipping breakfast, insulin use, severe hypoglycemia, dysesthesia of both feet, history of foot ulcer, photocoagulation, ischemic heart disease, and stroke. ORs for severe hypoglycemia increased significantly with the CES-D score in 2756 sulfonylurea and/or insulin-treated patients after multivariate adjustment including age, sex, duration of diabetes, glycated hemoglobin, insulin use, self-monitoring of blood glucose, leisure-time physical activity, skipping breakfast, dysesthesia of both feet, ischemic heart disease, and stroke (CES-D score ≤9, referent; 10–15, OR 1.64; 16–23, OR 2.09; ≥24, OR 3.66; p for trend <0.01).

Conclusions

Severe hypoglycemia was positively associated with the severity of depressive symptoms in Japanese patients with type 2 diabetes independent of glycemic control, insulin therapy, lifestyle factors, and diabetic complications. As both severe hypoglycemia and depression are known risk factors for morbidity and mortality in patients with diabetes, clinicians should be aware of this association.

UMIN Clinical Trial Registry

000002627.
Analytical performance, agreement and user-friendliness of six point-of-care testing urine analysers for urinary tract infection in general practice
Authors: Schot Marjolein J C , van Delft Sanne , Kooijman-Buiting Antoinette M J , de Wit Niek J , Hopstaken Rogier M
Published: May 2015

Objective

Various point-of-care testing (POCT) urine analysers are commercially available for routine urine analysis in general practice. The present study compares analytical performance, agreement and user-friendliness of six different POCT urine analysers for diagnosing urinary tract infection in general practice.

Setting

All testing procedures were performed at a diagnostic centre for primary care in the Netherlands. Urine samples were collected at four general practices.

Primary and secondary outcome measures

Analytical performance and agreement of the POCT analysers regarding nitrite, leucocytes and erythrocytes, with the laboratory reference standard, was the primary outcome measure, and analysed by calculating sensitivity, specificity, positive and negative predictive value, and Cohen's κ coefficient for agreement. Secondary outcome measures were the user-friendliness of the POCT analysers, in addition to other characteristics of the analysers.

Results

The following six POCT analysers were evaluated: Uryxxon Relax (Macherey Nagel), Urisys 1100 (Roche), Clinitek Status (Siemens), Aution 11 (Menarini), Aution Micro (Menarini) and Urilyzer (Analyticon). Analytical performance was good for all analysers. Compared with laboratory reference standards, overall agreement was good, but differed per parameter and per analyser. Concerning the nitrite test, the most important test for clinical practice, all but one showed perfect agreement with the laboratory standard. For leucocytes and erythrocytes specificity was high, but sensitivity was considerably lower. Agreement for leucocytes varied between good to very good, and for the erythrocyte test between fair and good. First-time users indicated that the analysers were easy to use. They expected higher productivity and accuracy when using these analysers in daily practice.

Conclusions

The overall performance and user-friendliness of all six commercially available POCT urine analysers was sufficient to justify routine use in suspected urinary tract infections in general practice.
Variability in potentially preventable hospitalisations: an observational study of clinical practice patterns of general practitioners and care outcomes in the Basque Country (Spain)
Authors: Orueta Juan F , García-Alvarez Arturo , Grandes Gonzalo , Nuño-Solinís Roberto
Published: May 2015

Objectives

To explain the variability in the frequency of potentially preventable hospitalisations (ambulatory care sensitive conditions, ACSCs) based on factors at multiple levels (individual, health professional, health centre and health district), and specifically using resource efficiency indicators for general practitioners (GPs).

Design

Cross-sectional study. We analysed primary care electronic health records and hospital discharge data using multilevel mixed models.

Setting

Primary care network of the Basque Health Service (Spain).

Participants

All the residents in the Basque Country ≥14 years of age, covered by the public healthcare system (n=1 959 682), and all the GPs (n=1193) and health centres (n=130).

Main outcome measures

Individuals admitted for ACSCs, over a 12- month period.

Results

Admissions for ACSCs were less frequent among patients who were female, middle-aged or from the highest socioeconomic classes. The health centre variables considered and GP list size were not found to be significant. After adjusting for the variables studied including morbidity, the risk of hospital admission was higher among individuals under the care of GPs with greater than expected numbers of patient visits and prescribing costs (OR=1.27 (95% CI 1.18 to 1.37); 1.16 (1.08 to 1.25)), and who make fewer referrals than the mean among their colleagues (OR=1.33 (1.22 to 1.44)).

Conclusions

When assessing activities and procedure indicators in primary care, we should also define outcome-based criteria. Specifically, GPs who are repeatedly visited by their patients, have higher prescribing costs and are more reluctant to refer patients to specialists obtain poorer outcomes.
Mindfulness-based stress reduction (MBSR) as sole intervention for non-somatisation chronic non-cancer pain (CNCP): protocol for a systematic review and meta-analysis of randomised controlled trials
Authors: Leung Lawrence , Han Han , Martin Mary , Kotecha Jyoti
Published: May 2015

Introduction

Chronic non-cancer pain (CNCP) affects up to 50% of the world's population. It impacts negatively on quality of life; entailing high costs on our medical systems, and translates to economic burden due to work loss. Aetiology of CNCP is complex and multifactorial, embracing the somatosensory, cognitive and affective domains. Opioid analgesia and other invasive interventions are often inadequate for clinical management of CNCP. Recently, mindfulness-based stress reduction (MBSR) has become a popular therapy for various medical conditions, including CNCP. However, studies reported varying efficacies, and relevant systematic reviews have included clinical trials with inherent heterogeneity either in study conditions or types of interventions used. Our study aims to provide an updated and more critical evaluation of the efficacy of MBSR as the intervention for non-somatisation CNCP.

Methods and analysis

A systematic review with meta-analysis of randomised controlled trials published in English will be performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines and the Cochrane Collaboration format. MEDLINE, EMBASE, PsychINFO, and the Cochrane Central Register of Controlled Trials Intervention, will be searched independently by reviewers using defined MeSH terms. Studies with full texts using MBSR as the main intervention on patients with non-somatising CNCP will be included. Outcome measures include pain scores and disability assessment scales. Continuous data will be meta-analysed using the RevMan 5 Review Manager programme. Primary analysis will adopt the random effects model in view of heterogeneity between trials. The standardised mean difference will be expressed as the effect size with 95% CIs. Forest plots, funnel plots, the I2statistic and the Cochrane Risks of Bias Assessment table will be included.

Ethics and dissemination

No ethics approval is deemed necessary. Results of this study will be disseminated via peer-reviewed publications and scientific meetings.

Trials registration number

PROSPERO CRD42014015568.
Efficacy of temporary work modifications on disability related to musculoskeletal pain or depressive symptoms—study protocol for a controlled trial
Authors: Haukka Eija , Martimo Kari-Pekka , Kivekäs Teija , Horppu Ritva , Lallukka Tea , Solovieva Svetlana , Shiri Rahman , Pehkonen Irmeli , Takala Esa-Pekka , MacEachen Ellen , Viikari-Juntura Eira
Published: May 2015

Introduction

Previous research suggests that work with a suitable workload may promote health and work retention in people with disability. This study will examine whether temporary work modifications at the early stage of work disability are effective in enhancing return to work (RTW) or staying at work among workers with musculoskeletal or depressive symptoms.

Methods and analysis

A single-centre controlled trial with modified stepped wedge design will be carried out in eight enterprises and their occupational health services (OHSs) in nine cities in Finland. Patients seeking medical advice due to musculoskeletal pain (≥4 on a scale from 0–10) or depressive symptoms (≥1 positive response to 2 screening questions) and fulfilling other inclusion criteria are eligible. The study involves an educational intervention among occupational physicians to enhance the initiation of work modifications. Primary outcomes are sustained RTW (≥4 weeks at work without a new sickness absence (SA)) and the total number of SA days during a 12-month follow-up. Secondary outcomes are intensity of musculoskeletal pain (scale 0–10), pain interference with work or sleep (scale 0–10) and severity of depressive symptoms (Patient Health Questionnaire, PHQ-9), inquired via online questionnaires at baseline and 3, 6, 9 and 12 months after recruitment. Information on SA days will be collected from the medical records of the OHSs over 12 months, before and after recruitment.

The findings will give new information about the possibilities of training physicians to initiate work modifications and their effects on RTW in employees with work disability due to musculoskeletal pain or depressive symptoms.

Ethics and dissemination

The Coordinating Ethics Committee of Hospital District of Helsinki and Uusimaa has granted approval for this study. The results will be published in peer-reviewed journals.

Trial registration number

ISRCTN74743666.
Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital
Authors: May-Miller Hannah , Hayter Joanne , Loewenthal Lola , Hall Louis , Hilbert Rebecca , Quinn Michael , Pearson Nicola , Patel Alisha , Law Rebekah
Published: May 2015

Quality of documentation is harder to quantify and incentivise, but it has a significant impact on patient care. Good discharge summaries facilitate continuity between secondary and primary care.

The junior doctors' forum led this project to improve the quality of electronic discharge summaries (eDS). Baseline measurement revealed significant room for improvement. We measured the quality of 10 summaries per month (across all inpatient specialties), against 23 indicators from the revised Academy of Medical Royal Colleges (AoMRC) standards (2013) that were prioritised by GPs as a “minimum dataset”.

Junior doctors felt that the Trust’s dual eDS systems were responsible for great variation in quality. This was confirmed by the results of a comparison audit of the systems in April 2014: one system greatly outperformed the other (57% mean compliance with iSoft clinical management (iCM) based system vs. 77% with InfoPath-based system).

We recommended that the Trust move to a single eDS system, decommissioning the iCM-based system, and this proposal was approved by several Trust committees. We worked with information services, junior doctors, general practitioners and hospital physicians to develop and implement a generic template to further improve compliance with AoMRC standards.

In August 2014, the iCM-based system was withdrawn, the new template went live, and training was delivered, coinciding with the changeover of junior doctors to minimise disruption. Median compliance increased from 66.7% to 77.8%. Quality of discharge summaries had improved across the specialties. There was a reduction in the number of complaints and positive qualitative feedback from general practitioners and junior doctors. Completion of discharge summaries within 24 hours was not affected by this change.

There is still more to be done to improve quality; average compliance with the full AoMRC standards (39 indicators) is 59.5%. With the approval of the Trust executive committee further plan, do, study, act (PDSA) cycles are underway, working to improve the remaining specialty-specific templates.
Standardising the organisation of clinical equipment on surgical wards at North Bristol NHS Trust: a quality improvement initiative
Authors: Ward Joseph , Spencer Robin , Soo Eleanor , finucane katherine
Published: May 2015

Poorly organised clinical equipment can waste significant amounts of time otherwise available for direct patient care. As a group of foundation year one doctors, we identified the organisation of clinical equipment across surgical wards at North Bristol NHS Trust to be poor with stocks often low and items frequently difficult to locate. Time-motion studies (n=80) were confirmatory demonstrating that the mean time to collect equipment necessary for venepuncture, cannulation, arterial blood gases, or blood cultures ranged from 121 to 174 seconds between different areas.

By applying a plan-do-study-act (PDSA) methodology, surveying peers as well as working with nursing staff and senior managers, we were able to purchase and implement clinical equipment trolleys on 10 surgical wards across the trust to reduce the time-taken to locate clinical equipment to between 38 to 45 seconds (p=0.01). We feel the key factors for the success of our initiative were strong multidisciplinary engagement and a simple uniform idea. Clinical equipment trolleys organised in a standardised manner have now been rolled out hospital-wide in the new Southmead Hospital Brunel building.
In situ simulation training in emergency departments: what patients really want to know
Authors: Yates Kim M , Webster Craig S , Jowsey Tanisha , Weller Jennifer M
Published: May 2015

Objectives

Despite the use of in situ simulation in the emergency department (ED) for training staff to better manage critical events, little is known about how such training is experienced by patients in the ED during these simulations. We therefore aimed to explore ED patient knowledge and perceptions about staff training for emergencies, as well as their views about simulation generally, and in the ED setting specifically.

Methods

In this qualitative study, we used an interpretive approach involving video elicitation and semistructured interviews with patients who were waiting for treatment in the ED. Patients who agreed to participate were asked about their knowledge of simulation and were then shown a short video of a simulated resuscitation from cardiac arrest. We asked participants open-ended questions about their perspectives on the film and their views and about simulation training in the ED. Interviews were audio recorded, transcribed and analysed using thematic analysis.

Results

We interviewed 15 participants. Most had little or no prior knowledge of simulation training. Watching the video elicited emotional responses in some participants, and pragmatic responses concerning staff training in others, with most participants viewing simulation training as useful and necessary. Participants said that to avoid unnecessary stress, they would prefer to be notified of when simulations were occurring, and what they could expect to see and hear during simulations. Most participants predicted that they would be willing to wait slightly longer (approximately 30 min) to see a doctor while simulation training was conducted, provided they did not require urgent medical attention.

Conclusions

Patient-centred care and care partnerships between patients and healthcare professionals underpin New Zealand healthcare and medical education ideologies. This requires effective communication between all parties, as evident in our study of in situ simulation training in the ED.
Predicting older adults who return to the hospital or die within 30 days of emergency department care using the ISAR tool: subjective versus objective risk factors
Authors: Suffoletto Brian , Miller Thomas , Shah Rahul , Callaway Clifton , Yealy Donald M
Published: May 2015

Background

We sought to evaluate the ability of the Identification of Seniors At Risk (ISAR) tool to differentiate between older adult patients having a poor outcome within 30 days of emergency department (ED) care and those who do not. We compare prognostic accuracy of subjective versus objective risk factors.

Methods

202 community-dwelling patients age 65 years and older presenting to two EDs were prospectively enrolled. Participants completed the six-question ISAR and objective testing (cognition, ambulation, vision). We reviewed electronic medical records for current medications, hospitalisations in the past six months, ED disposition, length of hospital stay, subsequent ED visits or inpatient admissions or death at 30 days. Participants were given a point for each risk factor present; subjective and objective risk factors were scored separately. We tested ability of individual risk factors and scores to predict a composite outcome of subsequent ED visit, postdischarge hospitalisation or death by day 30 after the index ED visit. We computed receiver operating curve area under the curves (AUC) to determine tool discrimination.

Results

23% of participants had a poor 30-day outcome. The optimum subjective ISAR cut-off score for screening was ≥2, which was present in 84% of participants, had a sensitivity of 91% and specificity of 19%. Using the subjective ISAR tool, the AUC was 0.66. The optimum objective ISAR-related risk cut-off score for screening was ≥3, which was present in 82% of participants, had a sensitivity of 87% and specificity of 40%. Using the objective ISAR-related tool, the AUC was 0.69.

Conclusions

The self-reported ISAR tool did not discriminate well between older adults with or without 30-day hospital revisit or death. An optimum score of ≥2 would identify many older adults at no apparent increased risk of poor outcomes at 30 days. Using objective ISAR-related risk factors did not improve overall discrimination.
Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services
Authors: Steele Sarah , Adcock Christopher , Steel Alistair
Published: May 2015

Objective

Social media (SoMe) are gaining increasing acceptance among, and use by, healthcare service deliverers and workers. UK Helicopter Emergency Medical Services (HEMS) use SoMe to deliver service information and to fundraise, among other purposes. This article examines UK HEMS use of SoMe between January and February 2014 to determine the extent of adoption and to highlight trends in use.

Methods

The database of the Association of Air Ambulances, crosschecked with UK Emergency Aviation, was used to identify flying, charitable UK HEMS. This search identified 28 UK HEMS, of which 24 services met the criteria for selection for review. Using information harvested from the public domain, we then systematically documented SoMe use by the services.

Results

SoMe use by UK HEMS is extensive but not uniform. All selected UK HEMS maintained websites with blogs, as well as Facebook, Twitter, Wikipedia and JustGiving profiles, with the majority of services using Ebay for Charity, LinkedIn and YouTube. Some HEMS also held a presence on Pinterest, Google+, Instagram and Flickr, with a minority of services maintaining their own Rich Site Summary (RSS) feed.

Conclusions

The SoMe adopted, while varied, allowed for increased, and different forms of, information delivery by HEMS to the public, often in real time. Such use, though, risks breaching patient confidentiality and data protection requirements, especially when information is viewed cumulatively across platforms. There is an urgent need for the continued development of guidance in this unique setting to protect patients while UK HEMS promote and fundraise for their charitable activities.
BET 1: use of a procalcitonin algorithm to guide antimicrobial therapy in COPD exacerbations can reduce antibiotic consumption with no increase in rates of treatment failure or mortality
Authors: Hankey Brandon , Riley Brad
Published: May 2015

A shortcut review was carried out to establish whether a procalcitonin-guided algorithm could safely reduce antibiotic consumption for patients with an exacerbation of chronic obstructive pulmonary disease attending the emergency department. Four randomised controlled trials were found directly relevant to the three-part question, combined within a later systematic review and meta-analysis. A further prospective cohort study was also found relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that a procalcitonin algorithm appears to be a useful strategy to guide initiation and duration of antibiotics and can reduce consumption without conferring additional risk. However, no cost effectiveness data are available as yet and further validation studies are required prior to widespread recommendation.
BET 2: negative B natriuretic peptide testing confirms low risk stratification for patients with a definite pulmonary embolus
Authors: Ferguson Craig , Horner Daniel
Published: May 2015

A shortcut review was carried out to establish whether a negative B natriuretic peptide could identify patients with confirmed pulmonary embolus at low risk for a complicated clinical course and therefore potentially suitable for outpatient therapy. Two systematic review/meta-analyses were found directly relevant to the three-part question. A further six prospective cohort studies of high quality postdating the systematic review were also found, relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that in normotensive patients with confirmed pulmonary embolism, a negative B natriuretic peptide or NTProBNP confers a low clinical risk of complications. When used in addition to a clinical risk scoring system such as the simplified pulmonary severity index, the risk becomes negligible (<1%). Such patients could be considered for outpatient therapy direct from the emergency department.
DEVELOPMENT AND IMPACT OF A DEDICATED CARDIAC ARREST RESPONSE UNIT IN A UK REGIONAL AMBULANCE SERVICE
Authors: Younger Paul , McClelland Graham , Fell Paul
Published: May 2015

Background

Survival rates from out-of-hospital cardiac arrest (OHCA) vary, with figures from 2% to 12% reported nationally. Our ambulance service introduced a dedicated cardiac arrest response unit (CARU) as a trial in order to improve local patient outcomes by focussing training, extending the scope of practice and increasing exposure to cardiac arrests. CARU launched in January 2014 using a rapid response car staffed by senior paramedics responding to cardiac arrests within a 19 minute radius of their location.

CARUService (CARU removed)2012 OHCA RegistryCardiac arrests where resuscitation was attempted547051,853ROSC (Sustained to hospital)35.2%25.8%23.0%Survival to discharge (Based on latest available data)13.0%3.3%7.0%

Methods

This work describes the development and impact of CARU during the initial six months (10/01/14 to 09/07/2014) of operations using prospectively collected data on all cases attended.

Results

CARU activated to 165 calls and attended 65% (n=107). 50% (n=54) of the cases attended were cardiac arrests where resuscitation was attempted. Return of Spontaneous Circulation (ROSC) was achieved during pre-hospital resuscitation in 52% (n=28) of cases.

Patient outcomes are reported compared with service data for January to June 2014 inclusive and one year of historical data from the regional OHCA registry:

Conclusions

Based on these figures CARU appears to have a positive impact on ROSC and a significant impact on survival to discharge rates compared with the rest of the service (p<0.01, Fisher's exact test). Further work is needed to explore how CARU delivers this impact and how the CARU model can be implemented beyond the trial setting in a sustainable fashion.
USING AN EDUCATION SESSION TO DEVELOP AMBULANCE CLINICIANS' UNDERSTANDING AND AWARENESS OF CHILDRENS DISTRESS, DISTRACTION TECHNIQUES AND HOLDING IN THE PRE-HOSPITAL SETTING
Authors: Preston Christopher , Bray Lucy
Published: May 2015

– Accepted for publication inJournal of Paramedic Practice
REVOLUTION IN PPI OR REVOLT? A MEETING OF MINDS OR A CLASH OF OPINIONS
Authors: Irving Andy , Broadway-Parkinson Andrea , Marsh Maggie , Fall Dan
Published: May 2015

Background

The PhOEBE (Pre-Hospital Outcomes for Evidence Based Evaluation) research programme aims to develop new ways of measuring how well ambulance services meet the needs of the patients who call them and the quality of the care they provide. Measuring how services are performing is important as it allows us to monitor if standards are being maintained, assess what works well and identify problems early so improvements can be made. The first stages of our programme have focused on identifying the range of possible measures and from these narrowing it down to a small number that we will then develop in more detail.

Methods

A Delphi survey was planned for PPI and ‘experts’ to score how useful they thought each potential measure was. At the outset of the survey preparation, the PhOEBE PPI group highlighted concerns regarding the accessibility of the method for a lay audience. Alternative means of involving patient and public views were considered. The PPI reference group co-designed a more interactive and accessible consensus event open to a wider PPI audience in order to consider those measures favoured by the Delphi expert panel. The event included presentations, small group discussions facilitated by the PhOEBE PPI ref group and electronic voting.

Results

Of the thirty one measures presented nine were voted as most relevant and important from a lay perspective.

Conclusion

This event not only provided the project with valuable information about which of our potential measures are considered important but also demonstrated that a PPI led initiative can enhance a lay audience's understanding of ambulance service performance issues. Despite some challenges in communication the event proved the PPI ref group as valued research collaborators. We continue to develop a more proactive PPI-led model of involvement capable of meeting the needs of the PhOEBE programme.
ARE PREHOSPITAL TREATMENT OR CONVEYANCE DECISIONS AFFECTED BY AN AMBULANCE CREW'S ABILITY TO ACCESS A PATIENT'S HEALTH INFORMATION? A UK SURVEY
Authors: Zorab Ollie , Robinson Maria , Endacott Ruth
Published: May 2015

Background

A shift from a predominantly emergency service, towards one where a wide range of conditions are managed and treated on scene presents numerous challenges for ambulance services and clinicians. The effective management of a broad range of patients and conditions in the ambulance setting will have an impact on other parts of the health service including emergency departments and primary care.

Methods

A two part online survey was distributed to operational staff working for a regional UK ambulance service. Clinicians were asked to report their experiences of accessing patient information and making decisions about patient management based on four hypothetical patient scenarios.

Results

A survey of clinical staff (n=302) revealed that overall, 285 (94.4%) of respondents felt that they had been unable to access health information about a patient that they were caring for, whilst 274 (90.7%) felt that this lack of information had led to a less appropriate care pathway being selected and the majority (246/81.5%) felt that information was easier to access during working hours on weekdays. Sources that respondents use when trying to access a patient's health information were mainly the patient's General Practitioner (n=294, 94.7%). Hospital Discharge and GP Summaries were the two pieces of information which respondents considered as helpful sources of information.

Conclusions

Decisions regarding the most appropriate care for patients presenting to the ambulance service are best informed by access to accurate and complete health information and records. An understanding of patients' pre-existing medical conditions, recent treatments and health information is needed for the selection of the most appropriate care; this information is often difficult to obtain in the ambulance service setting.
A SYSTEMATIC REVIEW OF RAPID ACCESS MODELS OF CARE AND THEIR EFFECTS ON DELAYS IN EMERGENCY DEPARTMENTS
Authors: Evans Bridie Angela , Porter Alison , Gammon Becky , Mayes Robert Harris , Poulden Mark , Rees Nigel , Snooks Helen , Toghill Alun , Wells Bridget , Whitfield Richard
Published: May 2015

Background

Pressure on emergency departments (EDs) sometimes results in handover delays for patients who arrive in ambulances, leading to operational disruption to the ambulance service and ED, and poorer patient experience. Some EDs have adopted models of care to provide rapid access for emergency patients to senior clinical staff.

Methods

We carried out a systematic review of studies describing the operation of a senior clinician-led rapid assessment team in an ED whose purpose was to streamline receiving, treating and discharging patients. We examined research papers published in English 2004–2014, searching eight electronic databases. We used a pre-defined data extraction framework and assessed papers for quality. We used narrative synthesis to analyse and synthesise the data on the characteristics of these models and their impact on patient flow.

Results

We identified 628 potentially eligible studies, of which 13 met the inclusion criteria for the review. Most were uncontrolled before and after studies (n=8); two were randomised controlled trials and two were controlled studies. The majority of models shared common characteristics, in addition to being led by senior clinicians: the patient was initially seen by a triage nurse, assessment and treatment occurred simultaneously with triage or followed quickly, and assessment and triage took place within a designated area of the ED. A wide range of outcome measures was collected. All studies which described effects on waiting times reported a reduction, generally across all patient groups. Seven studies reported that patients treated under the model spent less time in the ED between registration and discharge (up to 54% less in one study), with a range of impacts noted on other ED patients. Five studies reported that fewer patients left the ED without being seen. Five studies reported positive feedback from staff.

Conclusions

The review suggests that rapid access models in the ED may have benefits for patients, though evidence is still limited.
CAN WE REDUCE EMERGENCY HOSPITAL ADMISSIONS THROUGH EFFECTIVE SOCIAL CARE FOR OLDER PEOPLE?
Authors: Porter Alison , Morrison-Rees Sian
Published: May 2015

Background

Appropriate social care delivered at the right time can potentially maintain health and delay or avoid the need for health care interventions such as emergency hospitalisation. We describe a study, currently underway in Wales, which examines whether there is an association between the implementation from 2008 of policy aimed at reducing emergency hospital admissions among people with long term conditions and a change in provision of local authority-supported social care for people aged 65 and over.

Methods

This observational study of routine data employs mixed methods for data collection and analysis. We are using interrupted time series analyses (January 2006 to December 2012) to study overall trends in the use of social care and unplanned use of secondary care across Wales, and to examine the relationship between the two. We are examining how this relationship varies between local authority areas; over time; and by the type of care received, and the cost of care delivered. Within one case study area, we are using the SAIL database to link anonymously health and social care data, to examine service use at an individual level in the 65+ age group. We are using interviews with local authority data managers to explore the feasibility of extending this data linkage model to the whole of Wales.

Results

Analysis is currently underway on all-Wales data. Linkage of social services data with health data within the case study area is complete (91% match rate), and analysis will begin shortly. We have completed the majority of interviews.

Conclusions

There is potential to use routine data to examine the use of social care and the interaction with use of health care.
IMPROVING OUTCOMES FROM OUT OF HOSPITAL CARDIAC ARREST: THE CARDIAC ARREST INDIVIDUAL REGISTRY AND OUTCOMES PROGRAMMES (CAIRO)
Authors: Benger Jonathan , Voss S , Thomas M
Published: May 2015

Background

A cardiac arrest occurs when the heart stops beating suddenly. It is one of the most extreme medical emergencies. 60,000 people suffer an out of hospital cardiac arrest (OHCA) in the UK each year, with resuscitation attempted in less than half, and less than 10% surviving to hospital discharge. The Cardiac Arrest Individual Registry and Outcomes (CAIRO) Programme includes a comprehensive patient registry: the CAIRO database. This registry will allow us to confidentially link data from different sources to track each cardiac arrest patient from their initial collapse through to hospital discharge and, with the patient's consent, subsequently in the community through follow-up assessments of progress.

Aims and Objectives

To determine whether it is feasible to set up the CAIRO database in this patient population, by linking sources of routinely collected data.

To chart the patient pathway and estimate the completeness of the data obtained from routine data sources

Conditional on sufficient data being available to allow meaningful analysis;

Objective 1

To compare the survival to hospital discharge, ICU stay, complications and neurological outcomes in patients in whom the arterial oxygen concentration in the first 24 hours following cardiac arrest was or was not maintained between 60 mm Hg to 200 mm Hg.

Objective 2

To compare the survival to hospital discharge of patients who were or were not transported or transferred to a cardiac care centre within 12 hours of the cardiac arrest.

Objective 3

To compare the survival to 1-year of patients who underwent coronary angiography within 8 hours of the cardiac arrest or more than 8 hours after the cardiac arrest.

Objective 4

To compare the healthcare resource use to 1-year of patients who were or were not within 5 miles of the receiving heart attack centre when they had an OHCA.
REDUCING OVERTRIAGE AND UNDERTRIAGE RATES OF PELVIC FRACTURES AND UNNECESSARY PELVIC BINDER APPLICATIONS IN MAJOR TRAUMA PATIENTS
Authors: Trebilcock Hannah
Published: May 2015

Background

Data has been collected from suspected major trauma patient clinical records since the launch of the major trauma system in the South West in April 2012. In an internal report it was identified that 50% of overtriaged suspected major trauma patients were attributed to a suspected pelvic fracture. The National Consensus Statement on the Pre-Hospital Management of Pelvic Fractures provided a flow diagram depicting the appropriate application of the pelvic binder.

Method

An audit was conducted looking at all suspected major trauma patients from April 2012–March 2013. Two groups were selected for the audit. Group 1 consisted of the overtriaged patients where a SAM splint had been applied. Group 2 consisted of the undertriaged patients identified by TARN as having a pelvic fracture where no binder was applied. The flow diagram sited in the consensus statement was retrospectively applied to both groups of patients to confirm whether following the criteria would result in more accurate pelvic binder applications.

Results

In group 1, after applying the criteria specified in the flow diagram, there was a 15% reduction in unnecessary pelvic binder applications. In group 2 73% of the patients required a pelvic binder in accordance with the flow diagram criteria. Thus reducing the number of patients both over and under triaged with a pelvic fracture.

Conclusions

Applying the flow diagram criteria has shown to improve accuracy of appropriate pelvic binder applications in suspected major trauma patients. The flow diagram has been summarised into four key points and included in a new Trust Clinical Guideline for pelvic injury. A follow up audit will be conducted looking at the same groups of patients in the year following publication of the guideline to analyse whether accuracy of pelvic binder applications has increased.
PRE-HOSPITAL PAIN ASSESSMENT AND MANAGEMENT: A QUALITY IMPROVEMENT (QI) APPROACH
Authors: Lynde Jessica , Zorab Ollie
Published: May 2015

Background

Pain presents regularly in a range of medical and traumatic conditions. Ongoing monitoring for STEMI, limb fractures and major trauma, as well as audits on paediatric care have all indicated, however, that adequate pain management is not yet universal.

Involvement in the ASCQI project demonstrated the benefits of using QI methods to engage with clinicians, to identify barriers to providing evidence-based care and possible solutions. A QI approach was thus employed to tackle obstacles to optimal pain management, as part of the ASCQI Impact study.

Method

Trust clinicians were invited to join a Clinical Webchat, an online forum, to discuss pain assessment techniques and pain relief, including non-pharmacological methods. Clinicians shared their experiences and suggestions, and were guided by questions using audit evidence to provoke discussion. A thematic analysis of the Webchat transcript informed recommendations for clinical managers and trainers.

Results

11 clinicians took part in the Webchat, with representation from the Clinical Development and Audit teams. Participants agreed with the value of the existing pain scales to assist in titrating pain relief interventions. However, concerns that patients may over-estimate their pain meant clinicians use supplementary observations. Potential alternative methods were suggested for assessing pain. Practical issues with Entonox were uncovered, and the adequacy of the current formulary was questioned. It was accepted that non-pharmacological techniques were often overlooked, and innovative suggestions around use of distraction and combining analgesia with immobilisation emerged.

Recommendations included publicity around overlooked techniques; auditing pain management for specific groups; tackling localised and practical barriers to providing exemplary care; and further QI work exploring complementary pain assessment methods.

Conclusion

The Clinical Webchat is a novel QI method that can engage geographically-dispersed clinicians on a pre-prepared topic. Useful, generalisable information, added to audit findings, informed recommendations that could provide real and sustained improvements in patients' experience.
DOES CURRENT PRE-HOSPITAL CARE FOR PATIENTS AT THE END OF THEIR LIFE REFLECT BEST PRACTICE GUIDANCE?
Authors: Shaw Joanna , Fothergill Rachael , Murphy-Jones Georgina
Published: May 2015

Introduction

The end of life care good practice guide encourages organisations to enable terminally ill patients to be cared for and die outside of hospital. Ambulance services play a critical role in achieving this goal, however little guidance exists for ambulance crews.

Method

To determine the current levels of care provided, a retrospective review was conducted of 50 end of life care records. Findings were communicated to staff with a questionnaire to determine levels of confidence caring for these patients (61 responded); prior to a prospective review of a further 30 records.

Results

Only 4% of patients had out-of-hours information registered with the ambulance service. 48% were attended out-of-hours and their wishes were unknown. 38% of crews consulted with the patients' GP/palliative care team to determine whether the patient had a plan for their end of life. 88% of patients were conveyed (27% to a hospice and 73% to A&E). 53% of survey respondents were not confident treating this patient group. Respondents identified training needs, specifically on: alternative care pathways, evidence of terminal illness and DNA-CPR orders. Pain and discomfort was considered for 83% of patients, with subsequent action taken for 73%. Patients' wishes were not documented for 79%, however the patient's diagnosis and prognosis was clear for 97%. Referrals to A&E, a hospice or to the patient's GP/palliative care team were felt to be appropriate to the patient's presenting complaint for 93%.

Conclusion

Crews are not able to access out-of-hours information for end of life patients and are therefore not always aware of the patient's wishes. The care provided to the majority of patients was good, but the questionnaire showed most respondents were not sufficiently confident when treating end of life patients. Further work is needed to ensure crews are able to determine patients' wishes and training could increase confidence treating this patient group.
IMPROVING PRE-HOSPITAL PAEDIATRIC PAIN MANAGEMENT
Authors: Shaw Joanna , Fothergill Rachael , Virdi Gurkamal
Published: May 2015

Introduction

Pain is one of the most frequently reported symptoms to UK ambulance services and pain management is a known area for improvement. This is especially true for paediatric patients who may not be able to communicate their levels of pain as effectively as adults.

Method

A criterion-based retrospective clinical audit evaluated pain assessment and management for children less than 12 years old who reported a suspected fracture. To determine how pain assessments could be improved, an investigation of pain assessment methods used in other areas of the NHS was undertaken. A laminated card was produced and distributed to all clinicians for use when assessing pain in children. The card contains an amended version of the Wong-Baker faces to help clinicians assess and monitor paediatric patients' levels of pain with a reminder of the analgesic options available for children. Paediatric pain assessment and pain management was re-audited following introduction of the card.

Results

Prior to introduction of the card, the data showed paediatric pain management as a considerable area of concern for the ambulance service. A pain assessment was undertaken for 64% of patients. When a pain assessment was undertaken, and the child reported they were in pain, only 23% of patients received pharmacological pain relief. The introduction of the card resulted in great improvements. A pain assessment was documented for 96% of patients, representing an improvement of 32% from the original audit. When analgesia was indicated, it was administered to 66% of patients, an improvement of 43%. Despite this improvement, pain was still not managed effectively for 34% of patients.

Conclusion

Further improvement is required to ensure every paediatric patient has their pain assessed and managed effectively. The laminated card has been redesigned and distributed, in conjunction with a pain training strategy. In addition, further analgesic options for paediatric patients have been investigated.
BETTER TOGETHER? AMBULANCE STAFF VIEWS OF HUMAN FACTORS IN RESUSCITATION
Authors: Miller Joshua
Published: May 2015

Background

Research into the care of cardiac arrest patients outside of hospital is limited. Evidence from hospital settings suggests that human factors including both technical and non-technical skills and performance may impact on care. This study sought staff views from a UK ambulance service aiming to investigate areas for improvement in resuscitation performance.

Methods

Volunteer ambulance staff responded to an open invitation to complete an anonymous internet-based survey. The survey used a mixture of closed questions, Likert-scaled answers and free text to explore staff views on resuscitation performance. Quantitative responses were presented graphically, and free text answers arranged by theme.

Results

111 staff responded to the survey. The results demonstrated that staff see effective teamwork as desirable in out-of-hospital resuscitation, but that this is not always the case currently. Staff felt more confident about practical skills such as cannulation and chest compression delivery. Difficulties were noted in: poor communication between staff members; inconsistent identification and nomination of leaders; low staff confidence in peri- and post-cardiac arrest conversations with relatives; and insufficient staff numbers on scene.

Conclusions

The findings demonstrate poor staff confidence in several non-technical skills, including teamwork and communication. Limitations of the survey included lack of recording of training received—where this has shifted in recent years from in-service to higher education routes—and missing demographic data.

However, the findings provide specific areas for improvement activity. This has already included best practice slides displayed in ambulance stations, and proposals for identification wristbands, a role-based work standard to reduce task omission and duplication, and a policy to send higher numbers of rescuers to cardiac arrest cases.
EndoLive UK 2015: introducing the best of UK endoscopy to the world
Authors: Smith Philip J
Published: May 2015

The inaugural EndoLive UK held in the International Convention Centre (ICC) Birmingham on the 12–13 March 2015 was a watershed moment for UK endoscopy and for the British Society of Gastroenterology (BSG). The event provided the perfect platform to demonstrate how the UK is delivering some of the highest quality endoscopic practice, training and research in the world. Organised by UK endoscopy experts and supported by internationally renowned endoscopists such as Professors Paul Fockens, Douglas Rex and Peter Siersema, EndoLive UK pushed back the boundaries of innovation and interaction during a ‘Live Endoscopy’ event.Frontline Gastroenterologysupported the event with a special edition of this journal dedicated toEndoscopic Practicein April 2015. With over 500 people from around the globe attending this first event, the aim of highlighting the very best of UK endoscopy on a national and international stage was achieved. Furthermore, the educational content of the course was developed to be accessible and appropriate to a variety of clinicians with different levels of experience—endoscopy trainees, nurses, General practitioner (GP) endoscopists, gastroenterologists and surgeons. This article reviews this event and its many highlights and successes.